IMPORTANT: Around 1992, I founded Operation Smile, a charity that helped provide free surgery for under privileged children in New York city. A few years later, I learned of another “Operation Smile” in Norfolk, Virginia, which provided free surgery exclusively for children in developing countries. I agreed to merge my charity, with this charity and join its board of directors. I helped raise millions of dollars for this Operation Smile and also went on two-week, Op Smile medical missions to Asia and the Middle East. It was on one of these missions that I came up with the idea for Smile Train. I am no longer a director of Operation Smile and this is my personal blog which is not affiliated with Operation Smile in any way.
Around, 1994 I merged a charity I started in New York called Operation Smile with another charity in Virginia which was also called Operation Smile. It seemed like a good match because our charity was focused solely on helping American kids and the Virginia Op Smile was focused solely on helping kids overseas. What could be better than a charity that helps both? I joined their board and helped started helping them raise money. But my favorite part was going on medical missions to amazing places such as China, Vietnam and Gaza City. It was an incredible experience to witness first-hand the power of these surgeries.
It’s called, “Everybody needs To Smile.”
I’ll never forget the first surgery I watched. It was performed on a little girl named Colorful Cloud in China. In just 45 minutes, our surgeon transformed her from a severely deformed child into a beautiful, smiling, 9-year old girl. It was like watching a modern-day medical miracle happened right in front of my own eyes. I was speechless.
I got to carry Colorful Cloud out of the operating room and into recovery where I waited with her dad for her to wake up. I wanted to be there when she saw how great she now looked. After about 15 to 20 minutes she woke up in a nurse ran to get a mirror. I’m never forget watching her hands tremble as she slowly raise that mirror and stared into it. I was expecting maybe hoping for her to let out a holler or cry for joy but she remained totally silent – just staring into that mirror with her hands shaking. I thought for a moment something might be wrong and I saw a single teardrop slip out of her right eye and down her cheek. And then another teardrop. And then another. And soon nine years of tears were pouring out of that poor little girl as she stared at her new face and her new life. I went back to New York City after the trip a changed man. That surgery didn’t just change her life, it changed my life too.
What made these miracle surgeries even more important was the fact that all the patients were extremely poor. Many had traveled many days and many miles to reach our partner hospitals. When word got out that an Op Smile mission was coming and offering free surgery for the poor, hundreds of children and their parents would show up because they knew it might be their last chance to ever get surgery for the child. They would show up with no money, no food, shoes, nothing but the tattered clothes on their backs. Most could not read or write, and many of them have made great sacrifices to get there. Some had sold their rickshaws – their only way to make a living, others have taken loans from family or friends. They would do anything and everything they could to get to our partner hospital and give their child a chance for surgery. 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 about 10,000 pounds of medical equipment and build out operating rooms that were similar to those in US hospitals. The team typically would spend the first week screening patients. On average, 300-400 children who desperately needed surgery would show up with their mom or dad or grandmother or neighbor. They would register, undergo an examination by a doctor and then they would wait and see if they were one of the chosen few that would receive surgery. All the surgeries would take place the second week. Then it was time to pack up all of the 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. With only enough surgeons and resources to help around 100 kids, we would post the names of the lucky kids on a list and then someone, usually a nurse, would have to tell 200 to 300 mothers that we were “very sorry,” but their child would not be receiving surgery.
What usually followed was very hard to watch. Every mother would cry and plead for their child. Some would throw themselves on the ground, begging for their child to be helped. With tears streaming down their faces, they would beg: please, please, please add one more child to the list. Please save my child. But the answer stayed the same. We’re very sorry.
We quickly tripled Op Smile’s annual revenue. But as an economics major, I knew raising more money was never going to be the answer. Doubling our missions would only mean turning away twice as many kids. We didn’t need more money, we needed a new business model. The mission model was great for a small Mom and Pop charity that wanted to help a couple thousand kids in year. But my dream, was to help provide not a hundred surgeries a year, but a hundred thousand surgeries a year. I wanted to solve the problem of clefts. And it was clear to me that missions could never scale up to 100,000 surgeries a year for many reasons.
The mission model is way too 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. Impossible. At the time, Op Smile was barely raising $3 million a year.
The mission model isn’t scalable. An average mission provides only 100 surgeries which means to provide 100,000 surgeries, you need to send 1,000 missions a year and recruit 40,000 volunteer doctors and nurses. At the time, Op Smile had a couple hundred volunteers and was sending 23 missions a year.
The mission model is not sustainable. Missions breed dependency – not independence. Op Smile’s busiest mission site today is the first place it ever sent a mission: The Philippines. Over the past 38 years, 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 Filipino parents prefer American surgeons.
To solve the problem of clefts, we needed a new business model that could:
- Dramatically reduce the cost-per-surgery.
- Scale up to at least 100,000 surgeries a year.
- Help very poor but very proud communities become self-reliant.
I found the answer in Bac Thai, Vietnam on an Op Smile mission. 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. “Actually, most of them are better cleft surgeons than the ones we bring on missions.” he told me. “It’s because they do many more cleft surgeries than we do.
A Vietnamese surgeon might do 500 cleft surgeries a year whereas an American cleft surgeon might do just 10-15 cleft surgeries a year. Most volunteer surgeons who go on Op Smile missions are not cleft surgeons and some haven’t done a cleft surgery since med school.
This blew my mind. We were 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 would dramatically reduce the cost per cleft surgery while the numbers of surgeries would soar. AND this new business model was scalable and sustainable. It would 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 who do thousands of cleft surgeries a year are probably better at cleft surgery than volunteer surgeons from the U.S. who do 15 cleft surgeries a year. This approach would be so much less expensive and local surgeons and nurses could operate every day of the year – not just one week a year.” It was all so clear to me. This could be the new business model we had been searching looking for. I couldn’t understand why this American volunteer surgeon wasn’t as excited about this 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 just might be a very, very big idea. When I returned to New York, a small group of us started to quietly work on this bold new idea of empowering local surgeons in developing countries.
When I say “a small group” I really mean Delois Greenwood and me. Delois 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 – it never would have happened without her.
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 and had been born in Shanghai. I was hopeful he and or his company might give us a big, start-up 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 train would leave behind well-trained surgeons and medical equipment so they could keep operating long after the train was gone.
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.
My partner and super talented art director Mike Schell deserves all the credit for the design of the concept train and logo. Once Mike put the huge faces on the side of the train, the name became very obvious. This logo and these designs really made it easy to communicate this idea and to get support.
Virtually everyone we showed it to loved it – except for two people, Bill and Cathy Magee, the two co-co-founders of Operation Smile. He was a dentist and she was a social worker. They started Operation Smile in 1982 with their first mission to The Philippines and had been going on missions for almost 20 years – it was all they knew. So when they heard about our idea of empowering local surgeons they immediately rejected it. I was disappointed and surprised because our Smile Train idea might mean we could stop turning away thousands of children every year and also because it came with a $10 million pledge from Wang’s company. A pledge which was ten times bigger than any donation Operation Smile had ever received over the previous 20 years. The co-founders asked that the Op Smile board reject the $10 million pledge and they had a long list of reasons why: they said Smile Train was too “China-centric ”, it was too “risky” to let local surgeons do the surgeries and it was too “Asian.”
Another reason which no one dared mention was some may have considered our Smile Train Project as competition to a pet project the Magees had been struggling to get off the ground for years. They called it The Pope Project and it was a massive PR project that would bring a thousand children with unrepaired clefts, from very poor developing countries all around. the world, 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, after surgery, Op Smile would fly all of these children back to Rome, a second time, to see the Pope again, and to celebrate their new smiles and new lives. For a tiny mission charity like Op Smile that turned away thousands of children every year due to lack of funds, this Pope Project seemed a little extravagant.
But the Op Smile co-founders actually ended up doing their Pope Project – without the Pope. They got a rich donor to give them a very large grant ($7+ million?) with which they rented a very large plane and flew themselves, a few surgeons and Ronald McDonald around the world. They would stop in each country, operate on a couple kids, do a lot of interviews and TV appearances and then take off for the next country. Just as many of us feared, it was an extremely expensive PR stunt and it generated little to no publicity in the U.S. The cost of jet fuel alone could have provided surgery for tens of thousands of children.
At the Op Smile board meeting where I announced a $10 million pledge in support of the Smile Train Project, from Wang’s company, Computer Associates, the co-founders did everything they could to stop it. Bill Magee, a dentist, told the board that he was the only doctor on the Op Smile board and he knew“children will die” if the Smile Train ever got up and running. He claimed it was risky to allow local surgeons to perform the surgeries. This, of course was not true at all. Over the next 25 years, Smile Train has provided almost 2 million cleft surgeries through the hearts and hands of local surgeons and the results show that local cleft surgeons are much more proficient than American volunteer surgeons because they do so many more cleft surgeries. Over the objections of Bill and Kathy Magee, the Operation Smile board voted overwhelmingly to approve the Smile Train Project. We moved ahead with this idea which was managed as a special project of Operation Smile. But the co-founders never supported the project and did everything they could to undermine it. So in 1999, after two young children died needlessly on an Op Smile mission in Beijing, China, due to what appeared to be negligence, as outlined in a New York Times’ front page expose, Wang and I resigned from the Op Smile Board – along with a few other directors. We decided to to spin Smile Train off as a completely independent charity with no ties to Operation Smile. We took all the money we’d raised for the Smile Train project (around $4.5 million), and left Operation Smile. As part of our “divorce”, the Magees demanded we destroy the Smile Train name and logo and never use it. Thankfully, we ignored their demands.
Neither one of us had ever started a charity before, but Wang and I did know that there were millions of million children with unrepaired clefts in developing countries waiting to be helped.
And we we determined not to let them down.
