Good Reads: Before and After by Brian F. Mullaney, Co-Founder of Smile Train and WonderWork.
Before and After: Chapter 13
After the success of our two missions to Haiti, we decided to begin funding traditional mission groups on a more regular basis into those areas where there simply weren’t local doctors for us to partner with. We funded missions to Iraq and Afghanistan, to Peru and Liberia. In total, we ended up funding 100 mission groups a year, traveling to 20 different countries. While our principal delivery model of empowering local surgeons remained central to our work—it was the model through which we were able to provide 100,000-plus surgeries each year—we recognized that if we needed to change course in order to reach more patients, then so be it. We had learned a vital lesson: founding principles are important, but not if they become dogma. Helping as many patients as possible was always going to be our bottom line.
In the end, funding these missions offered us a chance to learn another, perhaps even more surprising lesson. When we started Smile Train, many eminent professionals in the medical field told us that we had lost our minds. How could we trust surgeons in the developing world to do a good job? If children died during surgery, we were going to be responsible! The prevailing assumption was that doctors in the developing world were underqualified and that only highly trained American doctors could guarantee good outcomes for patients.
“Teach a man to fish” became the Smile Train rallying cry, in part because we believed that the naysayers were being too condescending, and that the mission model was outdated and overly colonial. We believed that empowering and training surgeons was a more modern, sustainable approach—but that didn’t mean we weren’t nervous. Those naysayers had gotten under our skin. When we started Smile Train we were convinced we were going to have to offer ongoing training, continually monitoring and supporting developing world surgeons in order to maintain quality outcomes.
As we closed in on a decade of Smile Train surgeries, we kept analyzing the data from our many hundreds of thousands of medical charts in our electronic database. Now that we were funding Western mission groups as well, we had access to their scores, too. Like all doctors participating in the program, US mission doctors had to submit electronic medical records, so for the first time we could do some basic analytics to measure quality and safety of our developing world partner surgeons, comparing their outcomes to those of doctors from the United States. Here’s what we learned.
The vast majority of our developing world surgeons were scoring extremely high on our ratings scale that measured quality of outcomes; the quality of care they were delivering to patients was uniformly impressive. Meanwhile, the American mission surgeons scored surprisingly poorly, some well below the median grade. Why was this the case? Surely you would think the American surgeons would have the better scores. They had gone to some of the finest medical schools and worked in the best hospitals in the country. But our surgeons in the developing world had one advantage that the American surgeons lacked: sheer volume of surgeries. Our partner surgeons were working to clear a vast backlog of clefts. As a result, they might perform more than 500 cleft repairs in a year. By contrast, a surgeon in the United States might only see 10 to 20 primary cleft cases in a year. In surgery, as with any skill, practice makes perfect, and it turns out volume is a very good indicator of excellence.
I confess, this besting of the American surgeons scores by our partner surgeons felt like validation for our Smile Train model. From the beginning, we had always said that surgeons in the developing world were more than capable of performing surgery if they were just given the support and funding to do so. But it also made us realize how condescending that phrase “teach a man to fish” must have seemed to our local surgeons at the outset. They were clearly more than qualified to do their work, and nine times of out of ten, they needed our money more than our instruction. Rather than “teach a man to fish,” we should have been saying, “supply the man with a rod and money for bait.”
Over the years, many members of our American medical advisory board traveled to visit our partner surgeons in the field to observe their work. When they came back, they also expressed that they were not only impressed, they were humbled by what they had seen.
One of our advisors, Dr. Eric Hubli—a very talented pediatric surgeon from Texas—once visited our Smile Train partner at the Guangxi Autonomous Regional Hospital in one of China’s southernmost provinces. During his visit, Dr. Hubli told me, he was scheduled to observe a surgeon in the OR at Guangxi—his name was Dr. Pan. The first thing that Dr. Hubli noticed about this surgeon was that Dr. Pan looked very young. Dr. Hubli was immediately wary, assuming that Dr. Pan was inexperienced. Then, during the surgery, Dr. Hubli watched in dismay as Dr. Pan made incision after incision in the patient’s lip—over twenty-five cuts in all. Thank goodness I’m here to help clear up this mess! Dr. Hubli thought. Then he watched as Dr. Pan sewed up the lip with a series of deft and intricate stitches, his fingers moving at a rapid pace.
After five minutes, Dr. Pan’s repair was finished—and it was perfect.
“That was fantastic,” Dr. Hubli enthused after the surgery. “I never saw anyone do it that way before!”
Dr. Pan was evidently pleased by the compliment. He disappeared into his office, returning with a copy of a major Chinese medical journal where he had published an article about his technique ten years prior. Dr. Hubli is an exceptionally accomplished and respected cleft surgeon in the United States, but he had never heard of the technique. The surgery he witnessed that day remains one of the best he’s ever seen.
“We have so much to learn from doctors working overseas,” Dr. Hubli told me, “if we’re just prepared to open our minds and our eyes.”
There’s no doubt that during these years at Smile Train, I was undergoing a fundamental reevaluation of so many of my beliefs and assumptions. With every trip I took, with every surgeon or patient I met, I was reminded of how much I still had left to learn about the world. Each trip brought about another fundamental shift in my thinking, and none more so than the visit DeLois and I took in 2010 to China’s Shanxi Province, on the border of Inner Mongolia.
We were here to meet Dr. Liu Xinhua, our partner surgeon in this region, and we couldn’t have found a better guide to the area. He had grown up in this remote province, the son of farmers, returning to help his community after receiving his degree in medicine. Broad-shouldered and tall, with a shock of thick black hair and a cigarette hanging from his mouth, Dr. Xinhua looked like he’d be more at home riding a horse bareback than taking up a scalpel for surgery, yet his commitment to helping children with clefts was unwavering. Each weekend, after a long week of performing surgeries at his hospital, Dr. Xinhua climbed behind the wheel of an old ambulance, driving around the local villages, searching for children with clefts. He visited the most remote corners of the province, places where families didn’t have access to newspapers, let alone a radio or television. This was the kind of grueling outreach work that Western doctors would find unimaginable, but Dr. Xinhua was tireless. Every weekend, he drove for miles, delivering pamphlets, canvassing marketplaces and local orphanages, where so many children with clefts end up after being abandoned by their desperate families.
A few months earlier, Dr. Xinhua had come up into the hills, to Yu Village. That day, he’d spotted a little girl with a cleft playing outside the family’s cave and asked to speak to her parents. When the mother came out to see what was going on, Dr. Xinhua told her that if the family could come to his hospital at Jingzhou, he could fix her daughter’s cleft right away, free of charge. The mother explained that she wanted nothing more than to have the child’s cleft repaired, but they had no money to get to Jingzhou. Dr. Xinhua assured them he would return the following week and drive them to the hospital personally. The girl’s operation had taken place a month prior to our visit.
Now we were going to visit the girl, Li Chuanhui, and her family. Dr. Xinhua drove us into the hills himself, in the old ambulance that he used to travel around the area, looking for children. We held our breath as Dr. Xinhua maneuvered this ancient vehicle, clinging to the curves of the mountainous road, the surface beneath the wheels turning from tarmac to mud, then from mud to ice. Without guardrails to separate us from the sheer drop below, Dr. Xinhua swerved with a surgeon’s precision around each hairpin bend. Every time he hit the brakes, the ambulance let out a shrieking noise, as if it was about to give out altogether.
Eventually the ambulance came to a sharp halt at a small commune made up of tiny, barren lots of land. Outside, it was about 20 degrees and we were shivering in our coats. The doctor explained that the rest of the journey would be made on foot. We followed him along a dirt path that stretched ever higher into the hills. Ahead, we could see clay-colored cliffs, patched with scrub and snow.
As Dr. Xinhua made long strides up the hill, we did our best to keep up. Soon we could hear dogs yelping and saw streaks of smoke in the sky. We were approaching Yu Village.
As we drew closer, I realized that what I had assumed were cliffs were actually terraces in the hillside, pockmarked with openings the size of windows. Dr. Xinhua and our translator explained that these were actually entrances to homes called yaodong or caves. Thousands of people in Shanxi live in dwellings like these, unable to afford anything else more substantial. Entire communities with no running water and no sewage system, surviving in homes dug out of rock. Up until that moment, I had no idea that in our twenty-first century there were still people living in caves.
We approached a row of the cave dwellings. Outside one of them, Li and her family were waiting.
Li was five years old and her hair was pulled tightly into two short pigtails. She had on a thin red coat that matched her cheeks, ruddy from the freezing cold. Little Li recognized Dr. Xinhua immediately and came running to give him a hug, but after that, for the rest of our visit, she clung to her mother’s legs, cautiously observing the Americans who had come to visit her family’s home.
Li’s parents led us inside a single, tunnel-shaped room carved out of the rock, with a clay floor and newspaper pasted to the walls as some kind of insulation against the dust. A single light bulb hung from a wire above our heads. There were only a few pieces of furniture. The whole family slept together on a large stone bed, and attached to the bed was a stove for cooking, which also funneled hot air under the bed to keep them warm at night. There was a frigid wind blowing through the cave and I tried to imagine how effective this rudimentary heating system would be against the elements.
Our translator explained that everything the family owned, they had grown or made themselves. The family’s prized possessions were three chickens, although they never ate the eggs, because they had to sell them for money.
Life was clearly very hard for the Chuanhuis even without the additional challenge of a child with a cleft. But what was extraordinary about these parents was that they had actually chosen to bring Li into their lives. Although they had an older biological daughter who was thirteen, Li was their daughter in name, but not by blood.
With the help of our translator, the mother told us her story.
One winter, about five years before, the mother had been walking to the river to get water. This involved a two-mile walk, down and then up a very steep hill. Along the way, she heard a baby crying behind a bush. She stopped to look and could see it was a newborn baby with a very severe cleft, probably just a few hours old. The baby was wrapped in a dirty blanket, lying on the dirt behind the bush. No one else was around. The mother knew she had to fetch the water for her family, so she turned and kept on walking. This was at 9 A.M.
Around lunchtime, she was on her way home from the river again when she passed the same bush again. The baby was still crying. She kept walking.
At 5 P.M., as the sun was setting and snow was beginning to fall, she went out to see if the baby was still there. It was.
Even though she already had a six-year-old daughter waiting for her at home, the mother knew she couldn’t leave a newborn baby outside to freeze to death. She picked up the baby and took it home, preparing herself for a fight with her husband about whether or not they should keep the child. Instead, when she showed him the tiny baby with the cleft—wrapped in her tattered blanket—the husband couldn’t help himself. He reached out and took one of the baby’s hands in his, blowing on it for warmth. Li had lived with the family every since.
As we listened to the story, we were struck by how special these parents were, and what a good thing they had done by bringing Li into their home. When they made the decision to keep her, they had no idea that there was a surgery for Li’s lip, and even when they heard that surgery was available, they assumed they’d never be able to afford to pay for it. Then they had met Dr. Xinhua. Now, just last week, the little girl had started school for the first time.
“You’re heroes!” we told them repeatedly. But the mother and father shrugged off our compliments, as if doing the right thing had been the only possible course of action available to them.
Later that afternoon, as we began to say our good-byes, Li’s father said he had something he wanted to give us. He started pulling at what looked like a small sack in his pocket. Our translator explained that the father had a bag of grain and he wanted to give it to us as a gift. I shook my head “no.” I was determined that he should keep this precious food for his family. But our interpreter whispered loudly that I was obliged to take the grain—local custom dictated that guests must receive a gift, and that the family would be offended if I refused. The father kept pressing the baggie into my hands, and so I thanked him, taking the gift as graciously as I could, while inwardly cringing at the thought of depriving this family of food.
I held on to that small bag of grain, carrying it with me all the way back to New York. I think about Li’s parents and their actions to this day. They saved a child’s life. They had taken Li into their home when they had barely enough food to feed themselves, for the simple reason that it was the right thing to do. In the West, if we stumble on a problem that we don’t want to deal with, we can call 911. If you were to find an abandoned baby on a street corner tomorrow, you could call the police, and as soon as they arrived, that baby would no longer be your problem. You wouldn’t have to take on the responsibility for raising that child. But the Chuanhuis didn’t have the luxury of passing on the problem to anyone else. Although they were barely literate and living on pennies a day, they had acted on a profound moral impulse—and because of them, Li was alive.
I had gone to Yu Village thinking that I was the generous one, helping to provide a surgery for this family that had so little. Yet I had returned with a gift. For me, the small bag of grain represented all the life-changing experiences I’d gained working at Smile Train, and the many incredible, generous people I’d met along the way, people I never would have encountered if I’d stayed on in my comfortable job on Madison Avenue. My visit to the Chuanhui family was a powerful reminder for me that charitable work isn’t only about giving—it’s about receiving, too. As I’d realized after my first mission trip to China, where I witnessed my first cleft surgery, this work is never completely selfless; in fact, it’s fundamentally selfish because you always get back more than you give. Perhaps the Chuanhuis understood the contradiction at the heart of every generous act. Was this the reason they had brushed aside our compliments when we praised them for their courage? Maybe taking in a child helped them to feel better, as if they could make a difference in their bleak and desolate corner of the world.
After we returned to New York, we made sure to send some extra funds to the family so they wouldn’t run short of food that month. We also sent Dr. Xinhua money for a new van—one with excellent brakes. This, too, can be seen as a self-serving action, because the last thing we wanted was to lose one of our best surgeons to the hazardous, icy, roads of those Shanxi hills.
Good Reads: Before and After by Brian F. Mullaney, Co-Founder of Smile Train
