I came back from India both exhilarated and determined. During our trip, I had met dozens of doctors, as well as many hundreds of patients and their families; it had been a dizzying experience, but I knew these numbers were just the tip of the iceberg.
By most estimates, there were two to three million unrepaired clefts in the world, and around 190,000 new babies were born with clefts each year. For us to be able to eliminate the cleft backlog and keep in step with new cleft patients being born all the time, we were going to have to forge partnerships with hundreds, if not thousands of doctors like Adenwalla. What I had witnessed in the hospital wards of India had touched my heart, but I knew that to put a serious dent in the numbers of clefts worldwide, I was also going to have to use my head.
Until that point, my role at Smile Train had involved standing in front of my PowerPoints, projections, and charts, and telling people what a great organization we were going to be—in the future. Now that I had stepped in as president, it was my job to turn a great idea into reality. I was nervous. We had made such big promises and had such big plans. Could we really deliver?
The first challenge was galvanizing our team. In my first few weeks on the job, I found myself faced with a small staff of eight very well-intentioned people who had been through two executive directors in as many years and who, unfortunately, had no idea what they should be doing. There were no job descriptions or goals or methods of evaluation in place, and there was no strategic plan, just a bunch of people talking about all the children they were going to help someday. I needed to get everyone focused on how many kids we were going to help today.
There’s an old saying: if you don’t know where you’re going, any road will take you there. I wanted us to know exactly where we were going, and to get there in ways that were strategic and mission-driven. In the aftermath of 9/11, I—like everyone else in America—had read the articles about the Red Cross, and the mishandling of donations that were meant to go toward helping people affected by the terrorist attacks. Seeing headlines like these made me even more determined to run a charity that used every cent we received to make the greatest impact.
Many of the changes I implemented around the office after I came on board were pretty basic. It was Business 101, starting with the bottom line: numbers of children helped. All our efforts, energy, smarts, and resources needed to be channeled to increase that number.
Each staff member was given a detailed job description with specific goals and targets. Everyone was told that they would be evaluated rigorously. If a staff member didn’t meet his or her targets, that would be a problem, and we were going to hold each and every member of the team accountable.
Once we had gotten basic expectations out of the way, we moved on to strategy. Partnerships were going to be at the very heart of Smile Train. We didn’t have a single surgeon on staff and we weren’t going to own or operate a single hospital. Our partner surgeons and hospitals would provide all the things we couldn’t: patients and surgeries. Meanwhile, we would provide the things they couldn’t: financial support for surgeries, training, and equipment. The more partners we gained, the more surgeries we could provide. The quality of our partners mattered immensely because it would dictate the quantity and quality of our surgeries. So, clearly, we needed more partners.
I started to apply everything I’d learned on Madison Avenue about good marketing and advertising to the task. We went to cleft symposia and conferences, and gave keynote speeches at surgical conventions, sharing our vision of eradicating the global problem of unrepaired clefts. We took out full-page ads in medical journals. We sent letters to every cleft hospital we could find—in China, in India, in Africa. And it didn’t take long before our phone was ringing off the hook. Every day would bring a new stack of mail from surgeons, nurses, and hospital administrators who were eager to become Smile Train partners. All of them were excited about our model of empowering local doctors. They, too, had gotten tired of the colonial model of mission groups swooping in, getting a lot of publicity for helping a handful of kids, and then leaving town, likely never to return. These local doctors didn’t want to wait on the sidelines anymore. They wanted to help their own communities on their own terms.
One of the biggest questions during these early days was how we could keep track of and evaluate the thousands of surgeries we were sponsoring every month. When I came on as president in 2001, patient records were still hardcopies. We had a tiny office in Beijing filled with boxes containing over 2,000 folders full of patient charts and photos. If we were going to help 100,000 kids a year, we needed a much more cost-efficient and manageable way to review and store all of these patient charts, so we decided to move to electronic medical records. (Writing this in 2016, that may seem like the most obvious course of action, but back in 2002, less than 1 percent of hospitals in the United States had switched to electronic records.)
The initial cost of going digital was high, but to use the language of business, we needed our capital investments to align with our strategic goals. It was a gamble, but it was absolutely the right decision for the future of our organization. After the database was in place, every Smile Train partner would be required to submit an electronic medical record for each surgery performed. This would enable us to review every record for safety and quality and guard against fraud. If everything was fine we would pay for the surgery, just like an invoice.
It sounds simple enough, but the challenges of implementing our electronic medical records were many. Most of our partners didn’t even own a manual typewriter, much less a computer, and even those who did have computers didn’t have broadband access. So we bought the computers and digital cameras. We gave them grants so they could afford broadband access. We provided training in using the application, creating records, and uploading them to the database. In the beginning, it was a slow and often painful process, but over time, our partners became adept at managing their records. This was a win-win because good recordkeeping meant our partners were serving their patients better, too.
After twelve months of tireless effort from our staff in New York and our partner surgeons overseas, we ran the numbers in advance of our annual board meeting. We were elated by what we saw. We had doubled our number of partners and tripled our number of doctors trained. We were adding new two new countries to our list of partnerships each month. We had increased fundraising from $300,000 to $1 million. Most importantly, we had funded 30,000 surgeries—a 500 percent increase from our prior year. By applying simple business principles and leveraging technology, our very small group of hard-working, committed people was able to have an enormous impact. And we had space to grow.
In many ways, Smile Train was the right idea at the right time. The twenty-first century had arrived, and across the board, people were acknowledging that existing models of aid were broken. Technology was exploding and globalization was a new reality. The time-honored tactic of airlifting in resources from above—without building any sustainability or infrastructure on the ground—was starting to be seen as seriously outmoded. Why would you send American doctors to China on two-week missions when there were 75,000 hospitals in the country with well-trained staff and excellent doctors?
We had proven that when you empower local doctors, the numbers of surgeries increase exponentially. It was extremely rewarding to watch this all unfold. As my year as interim president drew to a close, I knew I wasn’t ready to step down yet—there was still so much to do.
The good news was that we’d tripled the number of surgeries our doctors performed in a year; the bad news was that our startup money was rapidly dwindling. At our current rate of spending, we were going to empty our bank account in three years. If we really wanted to eliminate the problem of unrepaired clefts worldwide, I calculated we were going to have to raise in the region of $10 to $15 million a year. We had just spent the past year struggling to raise one million dollars. In terms of fundraising, we were at the very bottom of the mountain.
Back then one of our greatest problems was lack of visibility. Few people in America had any idea about clefts. Every year, 5,000 babies in the United States are born with a cleft. But every one of them receives surgery within the first few months of birth, rendering the problem of clefts invisible to all but those 5,000 families.
So how do you raise millions of dollars for a problem that no one is aware of? Making our job even more challenging, this invisible problem was happening on the other side of the world. And the unfortunate reality is that American donors prefer to donate to American causes that help American kids: charities that are close to their hearts, or at least close to home. We donate to cancer research because someone in the family has had cancer. We volunteer at a homeless shelter or soup kitchen because we see people sleeping on street corners. In general, we give money to overseas causes only when there’s a major disaster that’s widely publicized on TV and in newspapers.
This is a conundrum faced by almost every charity trying to raise money for overseas causes. How do you get people to care about problems happening thousands of miles away? Most Americans don’t travel widely outside of the United States, so they don’t see these problems with their own eyes. What’s more, the majority of donors tend to assume that the United States gives away too much money in foreign aid already. In fact, the opposite is true. We are the wealthiest nation on earth and one of the most philanthropic, donating over $350 billion to good causes in 2015 alone—yet 96 percent of that money stays in America.
The great Australian moral philosopher Peter Singer wrote about this phenomenon in 1971 in a famous essay about ethics called “Famine, Affluence, and Morality” (first published in an academic journal in 1972.) In it, Singer gives the following example: if you’re walking down the street and you see a child drowning in a shallow pond, of course, you rush into the pond to save the child. You don’t worry about getting your clothes muddy, you don’t hesitate—you race right in. But if someone tells you that 25,000 children die each day from completely preventable causes, you don’t even blink an eye. What else can you do? You’re just one person. What impact could your tiny donation possibly have? The subconscious reasoning is that if you can’t help everyone, there’s no point in helping anyone.
I understand this psychological reaction very well. For a long time, I didn’t feel that foreign causes were my problem, either. I was much happier helping people in my own community—if I helped anyone at all—because this felt concrete and tangible to me. When I was running the New York City schools program, I could physically see the kids on the subway who were in need. After I helped children gain access to surgery, I could invite them to my office and shake their little hands. This felt meaningful because the results were right there in front of me. I was the hero, rushing into the pond to save the child. But when it came to helping children overseas, it was much harder to for me to take the leap.
Going on that mission to China in 1994 completely altered my way of thinking. As I continued to travel, I learned about the dire conditions in which over a billion people on this planet spend the majority of their lives. I met a baby girl who weighed seven pounds at seven months and was literally starving to death in front of her mother’s eyes. I met families that were so poor they were living in huts made out of sticks and hovels made out of mud. I met day laborers working thirteen hours a day in 115-degree heat for 72 cents a day. I visited a village in India where little kids would shoot pellets from slingshots at trucks driving by with sacks of grain in the hope that a little grain would fall out on the road so they could eat. I met an old lady in Nepal who lived on a garbage dump where she scavenged every day for food and little pieces of plastic or aluminum she could sell. I saw poverty and misery on a scale that would appall most people accustomed to life in the West.
Those trips opened my eyes, and they opened my heart. I didn’t want to turn away anymore. I wanted to do my part. Yes, these children in need were living on the other side of the world, but like any other child, they had parents, grandparents, and siblings who cared about them. They had hopes and dreams for the future. They didn’t seem so different from American children anymore. They were my problem, too.
And I confess, the economics of global health work were also pretty persuasive to me, as well, as a businessman who wanted to make a real impact on the world. In countries where the US dollar has a lot of value, you can do a huge amount of good for drastically less money than you would have to spend working on homegrown causes.
In other words, after going on my first mission trip to China, I had undergone a complete change of heart. I consider myself a pretty average American, so I felt pretty confident that other average Americans could be persuaded, too. The challenge was to bring the global cleft problem to people’s living rooms, to let Americans know what was going on—but to do it in a way that would make them feel empowered to help. If I could show how a small donation could completely change a child’s life, I was certain people would feel incentivized and motivated to get involved. I wanted them to be the hero rushing into the pond that Singer described, rather than the person who shrugs his or her shoulders and walks away. I knew I couldn’t put every prospective donor on an airplane to witness what I’d seen on my travels. Instead, I had to find a way to bring what I had seen on my travels to them.
Cleft surgery takes about forty-five minutes and costs about $250. That’s all it takes to give a child a new smile and a new life. If I could only get that message across, I was sure American donors would respond. After all, how often do you get the chance to change somebody’s entire life for $250? That was the message—a pretty compelling one, I thought.
I went back to the medium I knew best: advertising, this time putting it to use to garner donors. A good friend of mine had a company that sold “remnant” advertising space in newspapers and magazines (leftover slots that no one had bought yet.) This ad space was available at discounts of 90 to 95 percent. So we started running regular ads in this discounted space.
Our early ads featured two photos: a “before” photo of a child with an unrepaired cleft, and an “after” photo of that same child, smiling after his cleft had been repaired.
INSERT PHOTO: SmileTrainAd
Before long, we started to see responses to these ads in the form of donations arriving at our offices. I began to make a habit of taking some time each week to read the letters and emails that came with them. There would be handwritten notes from children saying, “This is from my piggy bank,” accompanying a handful of dollar bills, or emails that said, “I’ve just been laid off from my job but here’s $25 a month I’m sending while I still can.” I learned about people who were struggling, but who still wanted to support our work. The diversity of our donors was incredible: middle class, lower class, upper class, rich, poor, black, and white. The one thing that they all had in common was the desire to help. Believe it or not, we even saw donations from people in prison.
People started holding fundraisers for Smile Train. One man asked people to sponsor him to swim the English Channel; another to climb Mount Kilimanjaro. Schools hosted lemonade stands, bake sales, car washes, decathlons, read-a-thons, and walk-a-thons. Churches, synagogues, temples, and mosques did the same. The owner of the L.A. Lakers held a poker tournament and donated all the proceeds to our organization. There have been Smile Train motorcycle rallies and Grand Prix races. In New Jersey, a little boy named Georgie Exarchakis, who had himself been born with a cleft lip and palate, decided to raise money for other children in the same situation who weren’t so fortunate to live in a country where clefts were repaired as a matter of course. At first, George went door to door with a bucket, raising money. By age eight, thanks to fundraisers at his church and within his local community, he had raised a total of $38,000.
When we did the math, we learned that the average amount of individual donations we were receiving was $50. It was incredibly gratifying to realize that Smile Train was being built, not just by a handful of millionaires with their large gifts (although those certainly helped!), but by ordinary Americans who believed in our mission. This tallies with recent research that shows that people with incomes below $25,000 give away, on average, 4.2 percent of their income, whereas those earning more than $150,000 a year give away only 2.7 percent. There have been plenty of studies done on why people with less are by and large more altruistic than those who earn more, but my theory is that if you’re struggling yourself, you simply have a greater sense of empathy for those in need. You don’t have to make that imaginative leap; you simply get it.
For the first few years of Smile Train ads, we stuck to the same format: a headline and a “before” and “after” photo. Then we did some additional market research. We learned that if we took away the “after” photo, donations went up significantly. What was going on? We’d assumed that people would love to see the “after” photos of children post-surgery happy and smiling. And people did love those photos. The problem was, that when potential donors saw the happy, smiling child in the “after” photo, on some subliminal level, they decided that the job had already been done, so there was no need to step in to help. Conversely, when we ran ads featuring the “before” child with his or her unrepaired cleft, potential donors understood that there was a problem and that problem hadn’t gone away. It was very hard to look at those images of children with holes in their upper lips, but it was also extremely motivating.
As time went on, we placed so many ads in so many different publications that they became a part of the landscape. To this day, when I mention to people that I co-founded Smile Train, they usually respond, “Oh, the charity with the ads in the newspaper!” Tens of millions of Americans heard about us this way—and also learned about clefts for the first time. The near-ubiquity of our ads helped us put clefts firmly on America’s radar. People didn’t shrug their shoulders when they saw our ads, and they didn’t feel powerless. They didn’t walk away. Something about our mission resonated with them, and thankfully, they decided to rush into the pond.
Over time, we even found a use for all those leftover “after” photos of smiling children that were languishing in our archives. The suggestion came from a donor: “Why don’t you send me a photo of the kid whose cleft I’ve helped to fix?” It was a brilliant idea. So along with a receipt and thank you note, we started sending each donor a “before” and “after” photo of a child post-surgery. We called these “fridge photos” because donors told us that they liked to pin them to their refrigerators. Fridge photos became an inexpensive and effective way to remind donors that they had helped give a child, not only a new smile, but a second chance at life.
Good Reads: Before and After by Brian F. Mullaney, Co-Founder of Smile Train and WonderWork.
