Bac Thai is a remote province several hours north of Hanoi, Vietnam right on the border with China.
I there on a two-week medical mission at a small hospital in Thai Nguyen.
As we drove north from Hanoi, we passed by dozens of cemeteries, filled with endless rows of what I assumed were anonymous graves.
I asked one of our doctors why they had so many cemeteries. He kind of laughed at my question and asked me how many Americans died during the Vietnam War.
That was easy to answer because I’ve been to the Vietnam War Memorial in Washington DC which displays the names of around 58,000 Americans who died or went missing during that war.
His next question was much harder. How many Vietnamese died during the Vietnam War?
Boy, I never thought of this. I took a guess, 100,000? 200,000?
The doctor just shook his head and told me something I couldn’t believe.
“Brian, more than 3 million Vietnamese died during the Vietnam.” He said. “That’s why there’s so many cemeteries and that’s why so many of the crosses have no names. The population of Vietnam during the war was around 40 million people. Around 13% of the entire population of the country was killed.”
I was in shock. I’m so used to people talking about the 58,000 soldiers that we lost and have never heard anyone ever talk about how many Vietnamese died.
It was very sobering. If America lost 13% of its population’s day it would mean about 43 million deaths. Unthinkable.
Another thing I noticed on the long bus ride north is that amidst the extreme poverty that we saw everywhere, everyone was working their tail off. Houses were being built, roads were being done, crops were being harvested, telephone poles were going up, kids were going to school, etc. I can’t tell you how impressed I was with the industriousness and work ethic that we witness over that three-hour bumpy bus ride.
As we get closer to a destination, the roads really deteriorated as he went deeper into the jungle. People were living in small lean-tos with roofs made of corrugated tin or palm fronds, you could see there was no electricity or running water, and as cars and trucks became more and more scarce, the number of bicycles soared.
As we pulled into small, rural, very poor village of Thai Nguyen, everybody stared at us as if we were driving a spaceship. I was told that they don’t get many visitors appear in the last outsiders that they saw more in the Chinese soldiers. They also told me that these villages had never seen Caucasians before!
I guess that was the closest I’ll ever get to feeling like a big movie star or celebrity because as we walked around the village, huge crowds surrounded us, took our photos and tried to meet us. They were very friendly, welcoming and smiling, many of them shouting, “Hellooooo! Hellooo!”
I was so relieved. After passing all those cemeteries I was worried about what kind of reception we might get. It has always amazed me how much the Vietnamese like America and Americans after what happened.
My business partner Mike Schell came along in this mission and our job was to get as many good patient stories and photographs as we could so we could produce some great fundraising materials when we got back home.
When we arrived, there was a huge crowd at the hospital. Word had spread that a team of American doctors was coming and would provide free surgery for the poor so hundreds and hundreds of kids and their parents, siblings, grandparents had come in the hopes of being chosen to receive surgery.
Some had come from long distances away and you could see the desperation in their faces. Even though the vast majority of these people were illiterate peasants who could not read or write, they knew enough to know that this could be there first, last and only chance to get surgery for their child.
When they saw the huge crowd this only heightened their anxiety about their child getting picked for surgery. Everyone knew only 100-150 kids would receive surgery.
As with most typical medical missions, the team spends the first week unloading equipment and setting up two or three operating rooms. And then it screens hundreds and hundreds of children to see what medical problems they had and who would make the best candidates for surgery.
All the surgeries are done the second week. Usually we only have the personnel and resources to operate on 100 – 150 kids. That meant on this mission, we usually have to turn away 200 to 300 children. That was by far the worst part of every mission, turning away 2 to 3 kids for every kid we would help. It felt like we were going backwards.
After get getting several hundreds of children and their families excited about receiving life-changing surgery, we only help a small percentage of those who show up – and turn away most of them. I hated that.
I met hundreds of kids and their parents on this mission. And I really connected with one of them. He was a little boy with a cleft, about nine years old, who traveled nowhere without his American basketball. Of course, there was no basketball hoop within 1,000 miles so he was usually kicking it around like a soccer ball with all the other young boys. They were mesmerized when I interrupted their soccer game and picked up the ball and spun it on my finger like American basketball players often do. After that, they loved hanging out with me.
The boy’s name was Hoang Nghia Quang, but that was so hard to pronounce, we all called him Soccer Boy instead. He had a very severe cleft. His front teeth protruded from the bottom of his nose at odd angles, and when he laughed, which he did often, you could see that the cleft extended all the way back into his palate, creating a deep furrow in the roof of his mouth.
Clefts come in all kinds of shapes and sizes. Some kids had very mild clefts which are easily fixed. But soccer boy and about a dozen of the other kids had very severe, large clefts that affected their lips AND the roof of their mouths, their palates.
Severe clefts can make life almost impossible for these kids. They can’t drink milk without it coming out their nose, they can’t eat or speak properly. Because of their appearance, they can never go to school, never get a job and never marry and raise a family. Often a cleft palate means a baby will die soon after birth because they cannot breast-feed.
And even if they live, a lot of children born with severe cleft lip and palate are malnourished. They suffer from severe speech problems. And even though their brains are fine, their speech usually sounds like they are mentally impaired — and so they are treated as such.
Since I merged my NYC charity Operation Smile with another Operation Smile charity in Virginia, I had learned a lot more about clefts. Clefts affect 1 in every 500 children, making it one of the most common birth defects in the world.
I learned that clefts have been around since the beginning of human history, and that they can affect anyone, regardless of race or creed or class. King Tutankhamun had a cleft palate. Abraham Lincoln’s son did too.
But in the days before modern surgical techniques, it didn’t matter whether you were a king or a peasant, you simply had to suffer your entire life.
Then, in the 1950s, doctors perfected all the surgical techniques necessary to do a great job repairing clefts. Most America kids born with a cleft receive anywhere from 5 to 10 to 15 different surgeries over the course of the next 20 years. By the end there is no trace of a class that all in the speech is perfect.
The developing world is very different. Children born with a cleft in developing countries do not receive surgery because the parents cannot afford it in the hospitals and government are too poor to provide free surgery.
Even though the surgery only costs a couple hundred dollars that might as well be a couple million dollars when your peasant and you make one dollar a day.
For the kids who are lucky enough to receive surgery, they usually only get one surgery. If they have a cleft palate they are in real trouble because speech therapy doesn’t even exist in most of these countries. In China, it is not even a vocation.
Soccer Boy’s cleft was one of the worst I’d ever seen. Which made his personality all the more remarkable? He was always in a good mood, always smiling, always positive. Many children that you see with clefts are quiet and withdrawn, always looking down, ashamed of their appearance in the way they speak.
Clefts have a real stigma and in many developing countries they are considered a curse or a mark of the devil. People in small villages often force families with a child with a cleft to move out because they think it brings bad luck.
In Soccer Boy’s case, his cleft gave him character and strength. He wasn’t going to let his cleft define him. And somebody really loved him because they brought them here to our partner hospital and now, he was going to receive the surgery that would change his life. I was really happy for him and had a great time getting to know him that week.
As always, the second week of any medical mission is the toughest. After week of setting up and screening hundreds of children in picking the lucky ones who would receive surgery, now you to crank out as many surgeries as we safely could in one week.
The medical team would wake up at six have a quick breakfast and be in the OR by 6:30 at the latest. Surgery would last from seven in the morning till late at night. We never know if we would ever come back to a location so we always tried to do as many surgeries as we could. We couldn’t tell a mom; don’t worry we’ll operate on your kid next year.
In Bac Thai, we were running three surgical tables, and each surgeon operated on 8 – 12 children day depending on the complexity of the cases. In addition to cleft surgery we also did other types of reconstructive surgery like scar revision and sometimes tumors.
The tiny hospital was overflowing with children either waiting for surgery or recovering afterwards. The medical team was exhausted but inspired. Just like a football team in the fourth quarter of a playoff game, everyone knew the importance of flawless execution. There was no room for delays or mistakes because that might cause some kid their opportunity for surgery.
It was inspiring to me to see all of these selfless volunteers who sacrificed their vacation time to come halfway around the world for two weeks to change so many lives. You could tell it was a labor of love for them and how passionate they were about helping others. I doubt that they get the same type of satisfaction from the surgeries they do back in the United States.
The best part about the surgeries was seeing the faces of parents when they saw how their children looked after surgery. The transformation is dramatic, immediate and lasts a lifetime.
We handed some babies back to their mothers after just one hour in the operating room in the change was so significant, they didn’t even recognize her own baby. They would say no, no, you made a mistake this is not my child. When they finally realized it was their child, they would completely break down. Crying, unable to speak, unable to stand, trying to thank the nurses and the doctors, trying to process just what this would mean to them and their child.
Cleft surgery changes everything in as little as 45 minutes. And it just doesn’t change the child who receives the surgery, it changes the parents who have been so worried about the future of their child. It changes the siblings who could never get married before since the family had a history of clefts. Cleft surgery changes their community, their neighbors, their village to see a modern-day medical miracle happen right in front of their eyes.
I had a front row seat for this all week, and it was something I will never forget.
The other most memorable moment was a frank discussion with one of our best surgeons. I asked him why the local Vietnamese surgeons didn’t provide any cleft surgeries. He laughed. “Of course, they do,” he told me. “They do cleft surgeries every day of the year. Except when we show up and they turn operating rooms to us.”
I was a little surprised because I had always been under the impression that only American surgeons could do these surgeries.
“Are these local surgeons any good?” I asked hesitantly.
“Actually, most of them are very, very good surgeons,” he told me. “It’s because they do so many cleft surgeries a year. A busy Vietnamese cleft surgeon might do 500 surgeries a year whereas a busy American cleft surgeon might do just 25 cleft surgeries. Not to mention the fact that the vast majority of surgeons that Op Smile sends on missions are NOT cleft surgeons at all and haven’t done a cleft surgery since med school.”
This blew my mind.
So, we were spending all this money sending American surgeons with little to no cleft experience halfway around the world to operate for 5 days in hospitals that already had surgeons and nurses that were providing safe, high quality cleft surgery every week of the year.
It didn’t make any sense and my next question just made it worse. “How much do Vietnamese surgeons make a month?” I asked him. “It depends on the surgeon,” he replied.” Between $300 and $1,000 a month.”
What? is this really true?
Are we really spending $1,000+ per surgery on this mission to Vietnam at a Vietnamese hospital where their clefts surgeons are paid $32 a day? Imagine what their cost-per-surgery is! Even better, imagine if we took the $120,000, we spent on this 2-week medical missions and instead, funded these local surgeons, nurses and hospital instead. How many surgeries could they do? 400? 500? 600?
This was the very first time I had thought about the idea of empowering local surgeons. Instead of sending American surgeons and nurses around the world for 2-week missions, perhaps the best way to deliver surgeries in developing countries was to empower local surgeons, nurses and hospitals?
The costs per surgery would plummet and the numbers of surgeries would soar. And this new business model was scalable and sustainable. This approach 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 had been patiently listening to me brainstorm and describe this new brilliant new business model and my crazy projections of helping 300%, 400%, 500%, more children than we were helping today.
But he didn’t share my excitement. In fact, he looked horrified. “You want Vietnamese surgeons to do the surgeries?” he asked me slowly as if I had lost my mind.
“Yes!” I replied, “Vietnamese, Chinese, Indian, Kenyan, whatever! You told me local surgeons are very good surgeons and they have much more cleft experience than most of our volunteer surgeons. Why not empower them to do the surgeries and lower the cost-per-surgery 80 or 90%? That would triple or quadruple the number of surgeries we are providing, and it may mean we never turn away a child ever again.”
It was all so clear to me. This was the answer we had been looking for, the new business model that would change everything. I couldn’t understand why this American surgeon wasn’t as excited as I was.
After a long pause he slowly said to me, “If we let the local surgeons do all the surgeries, then what will I do?” I didn’t know what to say to that. I just stopped talking. But my mind kept racing. And the seed for The Smile Train was first planted on that medical mission to Bac Thai, Vietnam.
And as soon as we returned to New York, a small group of us started to quietly work on this new idea of empowering local surgeons – instead of sending medical teams on missions.
When it was time to pack up and go home, everyone on the team had a huge smile on their face in such a feeling of accomplishment. Working day and night the team had succeeded in providing 150 life-changing surgeries for children no one else would help.
After five days, it was time to pack up and go home. Everyone had such a feeling of accomplishment—our surgeons had completed more than 150 surgeries.
As we said our good-byes to the local doctors, nurses, administrators and social workers, I kept looking around for Soccer Boy. I wanted to say goodbye to him, but he was nowhere to be found. So, I climbed aboard the bus.
As we pulled away from the hospital, a large group of kids started running behind the bus. They were waving at us and shouting the only English word most of them knew, “HELLO! HELLO!” We all went to the back of the bus to see this crazy crowd chasing us and to wave goodbye.
That’s when I saw Soccer Boy, running behind the others. I was so glad to see him until I noticed something.
My God, I thought, he still has his cleft –he never received any surgery!
He must not have made the list. And yet here he was, smiling, happily waving at us, wishing us well.
But I wasn’t smiling at all. How did this happen? How come my friend Soccer Boy wasn’t chosen? Why didn’t I pay attention and make sure he was? I was so upset, disappointed and angry I couldn’t even speak.
DeLois Greenwood, the former nurse and one of Operation Smile’s most senior managers was sitting right next to me. She didn’t know what had happened. She felt awful.
But what could we do? This is what happens on every Op Smile mission. 300 to 400 kids show up. 100 to 150 are lucky enough to make the surgery list. And the rest of the kids are turned away. That’s life.
And I’ve seen kids turned away and other missions, so I knew the drill. But this was different. This was my friend and I felt like I had left him down. I’m sure if I have insisted that he had surgery they would have accommodated me. I had let Soccer Boy down.
On the long ride back to Hanoi, on the long trip back to New York City, I was haunted by the image of that little boy running behind our bus, smiling, waving, yelling goodbye.
Soccer Boy was a tragic symbol of the thousands of children Op Smile had turned away over the years.
I thought I’d forget about it when I got back to work in New York, but I didn’t.
There had to be a better way.
