Evolution of a Sustainable Surgical Delivery Model
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SPECIAL EDITORIAL Evolution of a Sustainable Surgical Delivery Model William P. Magee Jr, DDS, MD sent home with no plans for a return visit. There were no physicians Abstract: For the past 28 years, Operation Smile has mobilized in the area that treated children with clefts. The chance was remote thousands of volunteers to provide life-changing cleft lip, cleft that any of these children would ever receive surgical care. palate, and other facial deformity surgery to more than 150,000 The governor of the province had invited Philpast to partic- children in countries all over the world. Our mission is to provide ipate on this trip, as he knew that there were many families that surgical care for children with the goal of developing sustainable had children with clefts who were untreated. These children were health care delivery models for surgical services worldwide. For literally imprisoned in their own body. The team brought their more than a quarter century, we have learned that good judgment own instruments and supplies packed with their luggage. Most of comes from experience and that experience comes from bad judg- the cleft lip surgery was undertaken using ketamine intravenously and xylocaine with epinephrine locally. Monitoring was done by ment. However, it has been woven throughout this sometimes stethoscopes and palpations of the dorsalis pedis pulse by an an- painful, always exhilarating growth process in which we have re- esthesiologist positioned between 2 stretchers while observing alized that our mission had so much more power than we initially 2childrenatatime. anticipated that it would. Originally, we focused on the face of a All the children were safely treated without any immediate child and our ability to provide a surgery that would change that complications. No postoperative team was left behind. Without child’s life forever. Today, we still stand in awe of the transformative doubt, these children were given a chance to live a normal life. power of this experience, but we have also realized the great power Having never been on a Bmedical mission[ before, to say that it was that lies in educating medical professionals and providing state- a powerful experience would be a massive understatement. The of-the-art equipment. For us, action took shape in the form of us images of poverty, hopelessness, and the needs of those families establishing a business model at home and in each of our partner were unforgettable. Because Philplast did not have plans to return to Naga City the following year, we asked Dr Riley if it would be okay countries. This included setting up financial reporting systems and to gather a group of our friends and return to help those who had creating program models that organized volunteers to provide care been turned away. This was the birth of Operation Smile. for children outside the reach of where surgery was currently available. Through our journey, we have realized that there is power Reason leads to conclusions. It is emotion which leads to action. in the healed face of a child. That moment gives us the opportunity to feel the passion for the service we have the privilege to provide. The memory of a mother, with a basket of ripe bananas in her It is that emotion that leads us to action. arms, and her 8-year-old daughter at her side with a gaping hole in her lip and nose will always stick with me. She said, BI would like to Key Words: Surgical delivery models, Operation Smile, cleft lip, give you these bananas, for it is the only thing I have to give you for cleft palate, genetic research trying to take care of my daughter.[ Her gesture came although we had turned her daughter away. With tears rolling down her cheek, and ultimately tears rolling down ours, all we could say was maybe HISTORY OF OUR ORIGINS next year. At this point, we knew that there was no next year. BReason leads to conclusions. It is emotion which leads to In November of 1982, my wife Kathy and I were given an [ incredible opportunity to travel to the Philippines with Philplast action. I would imagine that this is the way that most groups begin. (now Operation Rainbow from Oakland, CA) led by Dr Bill Riley. There was an obvious void when you compare the number of chil- The last of the 3 sites we visited during our 2-week trip was Naga dren who needed care with the amount of infrastructure available. City in the Camarines Sur region of the Philippines. This experience Therefore, groups such as Operation Smile will naturally be drawn would inevitably change the course and the direction of our lives. into areas that attempt to meet the needs that exist. The bottom line As a young plastic surgeon, I never could have anticipated the is, if there is a void, nature will fill it. We returned to Naga City with reality of what I saw. Three hundred children and their families pushed a group of well-intentioned people who were skilled in the medical forward into the crowded screening area with the hope that their child care we aimed to deliver. would be selected for surgery. We were only able to take care of approximately 40 children for the next 2 days while hundreds were FIRST AND SECOND LESSONS LEARNED During our second trip to Naga City, the leader of a church outreach organization in Manila organized a busload of children From the Eastern Virginia Medical School, Norfolk, Virginia. with untreated clefts to take the 12-hour ride to Naga. Our supporters Received March 9, 2010. in Naga were not thrilled that children from Manila were taking spots Accepted for publication March 12, 2010. in the operating room while their children were being turned away. Address correspondence and reprint requests to William P. Magee, Jr, We learned our first lesson in that we could not be everything to DDS, MD, Operation Smile, 6435 Tidewater Dr, Norfolk, VA 23509; E-mail: [email protected] everyone. Although there was an obvious need for the children of The author reports no conflicts of interest. Naga City and the children of Manila, if we did not stay loyal to the Copyright * 2010 by Mutaz B. Habal, MD children at the site in Naga City, we would have jeopardized our ISSN: 1049-2275 strong relationships there. In attempts to remedy this, we organized a DOI: 10.1097/SCS.0b013e3181ef2a6c second team to travel to Manila the next year. The Journal of Craniofacial Surgery & Volume 21, Number 5, September 2010 1321 Copyright @ 2010 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Special Editorial The Journal of Craniofacial Surgery & Volume 21, Number 5, September 2010 Because of this decision, we learned our second lesson. This titioners. It was also extremely important to have a strong business did not thrill many of the plastic surgeons in Manila who felt that structure and the capacity to raise funds in an open and transparent they had cleft care under control. It was with no intended malice on manner that was necessary to deliver this care. To say the least, these our part. However, in retrospect, it was insensitive and disrespectful painful lessons gained in our first decade of experience led to our not to approach (and in an ideal world incorporate) their leadership growth throughout the second decade. beforehand. We would learn many other lessons along the way as our organization matured. We expanded into Liberia and Kenya in 1987 and then into INTO OUR SECOND DECADE Columbia and Vietnam the following year. As our organization ex- As we entered our second decade, we learned that programs perienced major growth, we felt the need to expand our resources. It that we had started needed to be amplified and strengthened. became obvious that to create a sustainable model, we needed to add Although we had developed strong relationships with the countries well-trained colleagues from our host countries into the group. With that we were in, we now recognized the need for funding and the the help of a few very open-minded senior surgeons and anesthe- capacity that these countries had to raise money on their own. siologists, we held education days that included lectures and pre- Although we always recognized the importance of education, we sentations. They brought along their residents to participate, and knew that we also had to develop stronger programs in that regard. these young men and women became the catalyst for the organic We felt that to truly have a sustainable relationship, we had to create growth of what is now approximately 5000 volunteers worldwide. an adult-adult activity. Each group had to significantly contribute to As we began this expansion, we also realized that to become these processes. If not, an adult-child relationship would develop. sustainable, we needed more than just plastic surgeons. Without This leads to dependency not self-sufficiency. great anesthesiologists, nurses, pediatricians, dentists, speech pa- We began to raise money for fellowship and started our thologists, record keeping, child life specialists, and logistical per- Physician Training Program (PTP). Physician Training Program sonnel, the comprehensive care that was necessary could not be began in 1987 with a handful of surgeons coming to our head- given. In most of the mission surroundings, there was no capacity quarters in Norfolk, VA, for a 2- to 3-week period of intensive whatsoever for orthodontic treatment or speech therapy. However, it training in craniofacial surgery. At that time, Dr Paul Tessier was was obvious that if we did not demonstrate their importance by coming to Norfolk to work on craniofacial cases with me for including these specialties on missions, we would not show in a 2 weeks every 6 months.