COVID-19 Conversation: Going the Extra Mile in India and Madagascar

Our promise of improving health and dignity during the COVID-19 pandemic endures. We’re helping frontline health workers stay safe, nourished and empowered to better serve their patients by providing life-saving supplies and equipment, as well as remote training to bolster their response. We’re also providing nutritional assistance, hygiene kits and virtual health services to support people and their health needs so they can thrive. If you can, when you can, help us keep our promise to care for children and create hope for tomorrow.

Now, more than ever it’s our charge to safeguard the health and wellbeing of individuals around the world. We’re building upon our expertise in delivering cleft surgery and care in resource-limited settings as well as our history of improving the health and dignity of those we serve.

That’s why we’re finding the most meaningful ways that we can support people and their health needs in the communities where we work, even when medical missions are postponed, care centres are closed, and the future feels uncertain. It’s in this uncertainty that our swift action is required, and we’re doing everything that we can to help patients, families, and countries as this affects them.

While we’re still unable to provide direct patient care in nearly every place where we work, we’re beginning to resume direct activity in places where health authorities have deemed it safe to do so. In late May, we were able to resume providing surgeries in Vietnam and Italy.

This “COVID-19 Conversation” featured a live question-and-answer session on the topic of going the extra smile to support patients and families affected by COVID-19 lockdowns in India and Madagascar with Abhishek Sengupta, Operation Smile India’s executive director and regional director for India, Russia and Italy; and Dr. Howard Niarison, Operation Smile Madagascar’s COVID-19 programme coordinator and education and training coordinator. The session was hosted by John Streit, our managing editor and writer; and Laura Gonzalez, our digital content manager moderated the audience’s chat and questions.

Click here to watch past COVID-19 conversations.

Event Transcript

Laura Gonzalez: All right, we’re going to jump right in. Again, welcome everyone, thank you so much for joining this COVID-19 Conversation on going the extra mile in India and in Madagascar. My name is Laura Gonzalez, and I am the digital content manager for Operation Smile. I work a lot in helping to tell our story to our online audiences. I’ll kick it over to my colleague John Streit for his introduction.

John Streit: Hi, everybody. I’m John Streit, our managing editor and writer. Today, I’ll be moderating the chat and questions area of our conversation today. If you have any questions or any comments or want to discuss anything on the side while our panelists are talking, feel free to enter that into those two fields, and then at the end of our discussion with them today, we will have an audience Q&A portion, which I’ll be leading as well. Thank you all for joining.

Laura: Thank you, John. Now I am so excited to introduce you to our esteemed panelists today.

Leading this conversation, we have Operation Smile India’s executive director and regional Director, Abhishek Sengupta. Abhishek became involved with Operation Smile, first as a college student when he was recruited to translate Bengali to English for a medical mission near his school. Since then, he has grown with the organisation and has held many roles, including programme coordinator, programme manager and regional programme manager, which led him to his current position as the executive director of Operation Smile India, and the regional director in India, Russia and Italy. His organisational knowledge and expertise in international development are essential to our operations in India, a country with a tremendous need for cleft care.

We also are happy to welcome Operation Smile Madagascar’s education and training coordinator, Dr. Howard Niarison (I’m going to say that wrong. I have no French background, so thanks for your patience, Howard!) Howard is a doctor and graduate of the Medical School of Antananarivo in Madagascar. He has served with Operation Smile since October of 2019 as the education and training coordinator for our Global Essential Surgery project and, since April of 2020, as the COVID-19 programme coordinator.

Howard, Abhishek, thank you so much for participating today.

Let’s jump right in. Howard, what is the current state of COVID-19 in Madagascar, and how has the virus impacted day-to-day life and the way that we’re working with our patients?

Howard Niarison: Thank you for your question, Laura. First, hi, everyone, and we’re so happy to talk with you today. We’re going to talk about COVID-19 and this current state and the impact of this terrible virus. Unfortunately, unlike some western countries, Madagascar is now around the pandemic take. It’s shown by the incredible increase of numbers for two months now. Just to show you, on July 15th, we registered around 5,600 confirmed cases and 43 deaths. You may say for 26 million of people, it’s not that much, but it could be explained in part by a low testing capacity in the country. We have also two epicentres of COVID-19 now. First big one is Tana, the capital of Madagascar, the city where I am, and Tamatave; it’s on the east coast. Both regions are under total lockdown. In other regions, lockdown is reduced, but the sanitary emergency situation still remains.

All the facilities are now overwhelmed, then the government started last week to open three new COVID-19 treatment centres. It should receive around 1,000 patients, especially with symptoms.

Let’s talk a little bit about impact of COVID-19 virus. As we are part of a low- and middle-income country, the virus hit hard the country and still impact us more than others economically, socially. But because many shops had to be closed and many employers had to pull (out their) workers, unemployment, as like in many other countries in the world, an indirect impact of that is more shortage in security, because in daily normal lives, it already existed much in the country.

Concerning medical care delivery, we just need to keep in mind that in Madagascar, prior to the coronavirus, there is a lot of lethal disease like malaria, dengue, plague. And then medical care must go on into our bases of centres, which are pillar of our health system, vaccination, care for pregnant woman, care for babies continue. But at the higher levels, like regional hospital or university hospital, there’s more impact because when a hospital department is not overwhelmed, it’s quarantined. Then, only emergency surgeries and care are delivered now in the country.

Last point I would mention is that people are scared to go to the hospital now in the country. That’s why the government spreads the message of preventive measures and for those who get a chronic disease like diabetes, to continue the treatment and control. Thank you.

Laura: Thank you for painting that comprehensive picture for us. Abhishek, I know India has been pretty hard hit by the virus. Could you speak a little bit to the effects on both day-to-day life, but also the delivery of medical care?

Abhishek Sengupta: Sure, Laura. Firstly, a big thank you to everyone for joining us, and welcome. I hope the conversations today are insightful.

Laura, coming back to your question, I think India has been very significantly hit. What we realise now is that the virus actually came to India a bit later than when it came to other parts of the world. India did a very good job initially. It closed down its border, so international flights were cancelled, and the country went into a lockdown, and that the lockdown continued for pretty much two months, some parts even more than that.

The lockdown was implemented pretty strictly and very seriously. There was no movement within the country, there was no movement even within cities. People did follow it, and to some extent also forced to follow it because there was a huge amount of fines imposed. There were district officials and police officials who were making sure that lockdown was being followed.

I think throughout the lockdown, we didn’t see a huge spike in the number of cases, but since things started opening up, and the government was forced to open things up because of keeping economic intentions in mind because people were losing jobs, business were getting shut down. It had a very adverse effect on the economy.

Since the lockdown has opened up, there has been a huge spike in the number of cases. Currently, we have close to 30,000 cases a day, new cases. India is, in the next few days, going to hit about a million cases. We have 936,000 cases currently total.

A good thing is that India being a big country, of course a very highly populated country, but also a big country, we can’t look at India as a whole. You have to look at the regional disparities within the country. If you break down the numbers, what we realise is that out of all the cases, close to 83% of the active cases today, are actually concentrated only in nine states, which again is a good thing because you can – state governments are now putting very regionalised lockdowns at different states and cities to control the spread of the virus, as well as movement of people.

In terms of its impact on health system, of course being a late-development country, and given that India did not have a very robust health system even when it comes to primary health care, the impact has been significant. Like Howard was saying, it’s actually not just access to COVID patients for treatment, but also this has affected other patients, patients with other ailments including older population, as well as maternal and child health service delivery because people are scared to go to hospitals.

Two, actually, even doctors are scared in many hospitals. You read about it in newspapers, as well as we are hearing it from our medical volunteers, that a lot of times doctors are scared to even admit patients who have even the slightest of symptoms. They might not have COVID, actually.

That has created a bit of a havoc. The government currently is trying its best to handle the overwhelming need within the healthcare system. There are stadiums which have been converted into COVID wards and quarantine facilities. The government has taken up a lot of the private hospitals, as well as a lot of hotels have been taken up and converted into hospitals.

Indian railways have been supportive, and railway coaches have been converted into quarantine centres. There’s a lot of innovative thinking, and the government has done a really good job. Again, you have to look at it regionally because in India, health is a state subject. Different governments and different states are able to formulate their policy. Of course, there’s a directive from the central government.

I think overall, the situation with regards to the numbers, still is an upward trend if you look at the whole country. Of course, in the next few weeks, there is no chances of it plateauing or even coming down, but there is some hope if you bring down the numbers and look at it regionally.

I think currently, the government is prepared with the current caseload of COVID, but also slowly preparing for the worst, which is if the numbers exponentially start going up. I think it’s a new reality that we all are learning to live with. Like Howard was saying, one of the biggest challenges have been people with other ailments, who are not able to access health systems just because either they are scared, or even hospitals are not welcoming to these patients.

We hope that, socially, as we accept this as a new reality, I think people’s health-seeking behaviours are also influenced. Those are some challenges that, as a country, we can overcome.

Laura: I think that’s a great point. Howard, you spoke about the fear that people are having from going into medical centres. Could you talk a little bit more about what led to Operation Smile Madagascar’s decision to pause the delivery of surgical care?

Howard: Thanks for the question, Laura. First of all, the main factor is COVID-19 and its impact. Safety I think is the key word. We should maintain as much for patients as our volunteers. In one hand, we expected that there were partner hospitals where we usually do international missions will receive COVID-19 patients in the beginning, which is the case now in the country. In the other hand, there is a lot of people interacting during international missions. For example, just to show you, during our last mission here in Madagascar on March, we had around 450 patients, then you can easily imagine that it’s not feasible according to the actual situation in the country.

Secondly, a borders problem — it’s a big problem because, since the beginning of the pandemic, our government had to close all borders like all the countries. Most of our international volunteers are from various places in the world, and due to COVID-19, our borders closed as I said. Also, we don’t have enough credentialed local volunteers here to conduct a local mission in Madagascar, then it’s a big problem and the third factor in our decision to pause surgery too.

Another factor that I want to mention is that some patients are from very remote places in Madagascar and would not be able to join the mission site. In the country, some regions are under lockdown, as I said, and which means some roads are totally or partially blocked.

Laura: Is there other factors that your team in India considered pretty similar, Abhishek?

Abhishek: Yes, I think firstly, it was a bummer that we had to suddenly pause all our programmes because as you know, we had just come out of a big mission in Durgapur, where we have a centre. We had just finished up a big international mission where we did over 130 surgeries. And we actually celebrated 1,000 surgeries in Durgapur, which again was a big thing for us because Durgapur, being a pretty small town, being able to mount a centre there and doing 1,000 surgeries, we celebrated it. We had invited people from the local government, and there was a bit of sound and fury around that.

Then, right after the mission, COVID started impacting us. The primary reason to take that decision would be – the last surgery we did at the Durgapur centre was on the 22nd of March, and the country went into a lockdown on the 24th. The lockdown was announced on 23rd. We actually took a decision to stop surgeries right before the lockdown was announced.

For us, the biggest point of discussion that we had at that point of time was, one, patient safety and, second, volunteer safety. That is what we championed in Operation Smile, and that is something that we would never compromise. Whether it’s in our quality of surgery, the kind of services that we are delivering or any other external influence that might impact our ability to deliver services and quality treatment.

We realised that, although at that point of time, there were no cases in West Bengal, there were no cases in Durgapur. Actually, wherever we run programmes, there weren’t any cases, but we still realised that it’s not long that it’s going to hit us, even in these small towns and in the cities that we are working in.

We decided to stop programmes. Then just after a couple of days, we realised that it’s also a government mandate. Of course, we had to follow that. Like I was saying, the country went into a lockdown, elective surgeries were stopped in hospitals. Of course, for us, at that point of time, there was no question about not listening to what the government was saying.

Then truth be told, when we stopped surgeries, in all honesty, none of us could comprehend that this is how it would shape, that this is the shape this would take. We literally thought that it’s going to be like 10 days, 20 days, maybe a month and then we are going to start, then we are going to resume programmes. That’s how we conveyed the message to our patients as well.

At the centre, we have a list of patients waiting for surgery. We pushed them and we said, “Don’t worry. You are supposed to get surgery on 29th of March, we’ll get back to you on 1st of May.” Just push them by one month. Then slowly it dawned upon us that that’s not the case, and then we actually had to call up our patients and tell them that why we are not able to open the centre. There was a lot of logistics around that as well.

Currently, we have a lot of our patients calling us because kids who were 6 months old, they are now 9 months old. Kids who were 2 years old, just developing speech therapy, need for a palate surgery, are now 2 years and three months older. Again, it’s a difficult reality. We know that patients are waiting, and we are, of course, committed to try to get back as soon as possible to ensure that we provide them access to surgery. Of course, the primary and the most important thing we will keep in mind is safety of our patients, safety of our volunteers and our staff.

Laura: Thank you, Abhishek. The topic of this conversation, and what we’re about to dive into, is really both of your team’s commitment to going the extra mile. Although we can’t provide surgery, you guys have both come up with really innovative ways that we can help in our communities, and also help the patients that are waiting. Abhishek, could you speak a little bit about what your team has done to provide food and relief items to families and migrant workers in India?

Abhishek: Yes, absolutely. We are very proud of what we have done, firstly, because something that was off the beaten track, if I can say that, because it’s not something that we generally do in our normal course of work. Also, under the circumstances in which we have delivered this in Bombay, it’s pretty much exceptional.

Once we shut down our programmes, within a couple of weeks, we realised that, one, this is going to stay, and two, our teams were there and we wanted to help people. One way was to collaborate with hospitals and provide them with PPE, get our volunteers to help supporting as frontline workers in COVID wards and all of that, but then we realised that there were already people doing that. Plus, at that point of time, there was a huge shortage of PPE, so even for us to buy, it was difficult.

Then we realised that because of the lockdown, there was another challenge. India, as you would know, has more than 4.5 million migrant workers. These are people who come from small villages to smaller towns or bigger cities in search of jobs. All of them were working in the informal sector. They would work at restaurants, pubs, bars, factories, small businesses. Most of them are daily wage earners. Depending on the number of hours they worked a day, they would get paid at the end of the day. That’s how they sustain.

Also what happens is, these factories, these restaurants, these businesses where they work, that’s where they stay. At night, they would sleep at the factory. At night, they would sleep at the restaurant once it’s closed down. Because of the lockdown, suddenly all these businesses were shut. Suddenly, none of these people were being paid. They lost their jobs overnight, literally overnight. Most of them also didn’t have a place to stay because, like I was saying, they were still living in the factories itself, or in the place where they work, or even if they were paying rent in a big city, once their daily income is gone, they were not able to pay that rent. There were no trains to go back home. There were no buses to go back home. You would have seen that for about a month, you would see migrant workers literally walk for 7 days, 12 days, 14 days on the highways trying to go back home because there were no transport. There was no other way for them to go back home.

The other problem that happened is because these are people who pretty much live on a day-to-day basis, they don’t have any savings. Once they lost their jobs, there were a huge number of people who were actually living hungry, literally they didn’t have money to have two meals a day, leave aside three meals a day. We saw this as a problem, and we decided that that is a space we want to work in. Of course, we believe that it is our responsibility to stand beside communities even in times of hardship, especially in times of hardship.

We picked up two cities where we run centres. One is a very small town; another is a bigger city. One is Durgapur; the other one is Bombay. Bombay, as everyone knows, has the most number of migrant workers in India coming from different parts of (the country). We started giving out food supplies to them. Overall, in about four weeks, we were able to support about 2,500 families, providing them food supplies. In each packet, there would be rice, potatoes, lentils or cooking oil, enough for about 20 days for each family. Then, of course, we also gave some hygiene kits, which is masks, sanitisers, soaps, buckets and mugs, because we felt that is important in these times.

I think it was taken very well. And the idea was that, again, we knew from the beginning that we will not be able to support them for a long time, but again, the idea was to make sure they have enough support to get through these hard times when there is a lockdown going on. Then, of course, the hope is that once the economy opens up, they will go back to their jobs, start earning a salary and they wouldn’t need this support.

Laura: Can you talk a little bit about how we were able to utilise some of our existing partnerships to help us pivot in this direction of something that we’ve never done before in India?

Abhishek: Absolutely. I think one of our primary partners was the Inga Health Foundation. We partner in a lot of programmes with them. Everything that we did in Bombay was basically done in partnership with Inga. When we’re running centres in these two places, in Bombay and Durgapur, we actually already have existing partnerships with the local government, that’s the district magistrate, that’s the police as well as with a lot of NGOs in these areas because we do a lot of community awareness programmes through them.

This time when we wanted to do this, we went to them with a very different approach because they’re not used to hearing Operation Smile does this, but we told them that we wanted to support communities and provide food supplies. I think everyone was very welcoming. I must say that we could not have done it without the help of our partners because we really needed hands and feet on the ground. Of course, we had our teams, like you can see in this photograph, literally packing, as well as distributing supplies. Of course, we needed a lot more people, so we got volunteers from our partner organisers.

The other thing is, we got a huge amount of support from the local government in both these places. Because just imagine this was a time when there was a lockdown. Even our teams in these areas couldn’t leave their homes without the permission from the government. The government was kind enough to actually allow our people mobility. They were given passes so they could go purchase supplies, pack them, and then distribute them, and of course, a lot of support was provided from the local administration.

Then we went and distribute them, because just imagine going into a community with food for about 200 people, there is always overcrowding, and again, some things that we had to avoid at this time is overcrowding because we wanted to maintain social distancing. We wanted to make sure that enough precaution actually is being taken, and that’s where we got a lot of help from the local administration, as well as our partners.

Laura: Wonderful. Thank you for describing that for us. Now switching gears to Madagascar. Howard, your team has literally gone the extra mile by creating the Extra S’Mile Campaign. Could you talk a little bit more about what motivated that pivot from the foundation where you work?

Howard: Yes, sure, Laura. First, we really thank God we were able to make the Marh mission, but knowing that we won’t be able to make a mission for the rest of this year, we were so sad. As Abhishek said, the people here too are in a very bad condition, especially with food conditions. They may have just have one meal a day. They are living under $2 per day, too. Then the idea of going towards the patients instead of them coming to us came. It’s spreading miles to bring smiles. That’s how the Madagascar team gave birth to Extra S’Mile programme.

Laura: One branch of that campaign is called Extra S’Mile Nutrition. Similar too in India, your team is giving relief and food packs to families. Why is it so important that the families that we serve are receiving these essential items during this time?

Howard: Yes. As I said, it was so important for us to help poor families because they are in a very bad condition, as I said. They were so committed to bring them these food supplies because all of them live at the region under lockdown. That was our main criteria, bringing food supplies for those who were under lockdown, for those who can’t work, for those who can’t go out, for those who were under quarantine. The Smile Nutri-pack, that was the name of the food supplies, was supposed to last 15 days by delivering around 2,500 kilo calories per day.

In addition, we gave them reading material and flyers on healthy diet. We would like to show them how to eat properly, what to eat exactly to reinforce the immune system which will help them to fight disease more easily. Extra S’Mile Nutrition had two phases. We were able to visit six regions in Madagascar during phase one and phase two. We distributed Smile Nutri-packs to 532 patients and their families. Also, we were able to distribute 26 Smile Nuti-packs to 26 malnourished patients. Among them all, we are not forgetting our volunteers. We gave food supplies to 120 of them.

What is in Smile Nutri-packs? It’s quite similar with what Abhishek gave in India. We gave them 25 kilogram of rice, three kilograms of legumes, two concentrated milks, two bottles of cooking oil, two kilogram of sugar, one bar of soap, and, of course, five washable masks.

I just want to bring precision on what we’ve done for malnourished patients. We also gave them adaptive formula, therapeutic food. This to continue our existing nutrition programme here in the country because normally, in normal times, we cover all malnourished patients in the nutrition food camp for two days, but since it’s impossible due to the situation, we travel to each of their places.

In addition of that, for volunteers, we added N95 masks and sanitisers, as most of them are working in the hospital, on the frontlines against the COVID-19 war.

Also, there’s another aspect of extra malnutrition. We made the partnership with a local institution, National Office of Nutrition, here in Madagascar. Our main focus area was on the east region named Moramanga, because we heard from them that there’s a lot of people who are under quarantine, and they just threatened the government to go out because they needed food; they needed enough to eat. They were just hungry. That’s why we made this partnership with National Office of Nutrition by giving them these donations. And with local authorities’ help, we were able to give 30 kilograms of rice, two barrels of cooking oil and 12 kilograms of legumes to 145 households quarantined at home in Moramanga. It has the expected impact because number of cases in this region continue to decrease right now and that is our goal to contain the spread of this terrible COVID-19 virus.

Laura: That’s incredible. Your team should be insanely proud of the work you’ve been able to achieve and the hard work of travelling across Madagascar to deliver this type of relief. I understand that there are other focus areas of the campaign targeting hospitals, public awareness and then education-based webinars. Could you talk about some of the other focus areas?

Howard: Yes, as you said, Laura, we had three components of this Extra S’Miles programme: Extra S’Miles Hospitals, Extra S’Miles Awareness, and Extra S’Miles Webinar. For Extra S’Miles Hospitals, we gave PPE for health workers, professionals, and because most of them are testing positive now, and we wanted to make a difference by giving PPE and disinfecting products to help them facing this COVID-19 pandemic.

Also, Extra S’Miles Awareness, who made a partnership with another organisation, named MedAir, and they are working on another epicentre … They are spreading direct messages about COVID-19 to the larger public. But not only that, they are also acting on other several areas of prevention and control of infection, like agent training, disinfecting public places and those facilities, distribution of wash kits and PPE donation to all facilities.

The last component is Extra S’Miles Webinar. We are sharing to local partners and volunteers, most of them, mostly medical volunteers, relevant webinar concerning COVID-19 from Operation Smile (Global Headquarters).

Laura: Anecdotally, what have you been hearing from either the patients, the families, the volunteers, or the partners who we’ve been able to help with this campaign? What does it mean to them?

Howard: Yes, that’s a good question. It was a great mission because we mostly saw grateful eyes and smiling for those patients who received food supplies. They were so happy. We wish, of course, we could do more for more patients, but what we got from (Operation Smile Global Headquarters) and local donors here in Madagascar, they were a very big part of this project, (and they helped people who are) already very vulnerable. We did our best to provide the necessaries for those who mostly needed it. To resume, we saw happiness everywhere we travelled. Thank you.

Laura: Abhishek, you spoke about a lot of the obstacles that the country is facing in response to the virus, but could you speak about some of the obstacles your team is either currently trying to overcome or has already overcome in providing aid to these families, community members and then anyone else that you’re able to help?

Abhishek: Yes, I think initially it was a bit of a challenge for us because, first week, there had to be a big mind shift from where we are supposed to and condition to function because it was over and about what we are used to doing. There is some logistical challenges, especially in Durgapur. Mumbai was a bigger city so things were available, but in Durgapur, once the lockdown was in place, even supply chains were affected. Under those circumstances, trying to buy supplies, rice, potatoes, cooking oil as well as lentil in massive quantities was a challenge, and it took us a bit of time. It took us about a week to actually be able to procure things in a larger quantity, because by then, things were also getting streamlined by the day and the government also realised that that’s a challenge and supply chains were being streamlined.

The second was, like I was mentioning, that the first couple of times when we tried to do this I think there was a bit of overcrowding because we did not have much of an idea about that. But then, later on, we had understood so we’d send in advance teams, give out tokens first, make sure people are properly lined up and make circles and make sure they’re standing three metres apart from each other to ensure the social distancing norms.

I think those were the challenges it was just like there wasn’t anything extraordinary, but it was more of trying to do something for the first time. I wouldn’t call them challenges, but they were actually learnings. I think we were able to adapt fast and, of course, ensure that those issues were taken care of within the first week or first couple of weeks.

Laura: Howard, how about for your team? Did you have obstacles you had to overcome or did you turn them into learnings as well?

Howard: Yes, during this mission, phase one and phase two, of Extra S’Mile mission we had no major obstacles. At the beginning, the authorisation to proceed was a bit hard to get from the COVID-19 operational command, but with precious inward support, it went smooth. Also, I’d say that confirming the beneficiary patients from our database by call was a challenge too because we had to call them in advance to tell them the place, the date and the exact hour of distribution to tell them what to do. As Abhishek said, preventive measures like how to line-up, how many patients should come at this time, at this time but we’ve agreed, and through the incredible work of our patient coordinators, we were able to join and manage those 532 patients as well.

Laura: How has your team been able to stay in touch with the patients during this time?

Howard: Here in Madagascar, we have these patient advocates disseminated in different places. They are mainly parents of patients in the past. They are our main contact point in the country. They are responsible too of local awareness on cleft,  because they used to being in touch with patients. They are from the regions. Patients are not afraid of them. They are also the first responsible for follow-up of malnourished patients. Generally, when some patients have problems here, patient advocates are reporting to our patient coordinators and they are searching for a way to solve or to help those patients as much as we can do.

Also, through our (Ministry of Health) partnership, based in health centres, are a great help for us. For example, on following-up patients’ weight, it’s an important nutritional indicator, especially for our malnourished patients, because we have to remember that during this Extra S’Miles mission, we had 26 malnourished patients. These centres are also taking part of awareness by gathering newborn babies with cleft lip or cleft palate.

Laura: Abhishek, at the top of the call you talked about how you guys have been staying in touch with patients. Could you just elaborate on that a little bit more for us?

Abhishek: Yes. We have been in touch with patients. That’s one of the most critical things and that’s one of the most high-priority things for us because of two reasons. One is, it’s very important because there are a lot of patients whose treatment have been planned in the sense that they are either going through a long process of orthodontic treatment, or they are going through a process of dental treatment or speech or their surgeries have been lined up. That is the reason. There’s a lot of rescheduling happening. We keep pushing them.

In terms of the orthodontic patients, we’ve actually arranged phone calls with our orthodontist with some of these patients, because a few of them also have some fixtures that needs to be loosened, tightened and adjusted. That cannot be done without clinicians’ or orthodontists’ intervention. Our patient coordinators have been in touch with our patients, similar to what Howard mentioned. We also have patient coordinators across the countries in the different areas in which we work. One is, of course, planning, continuing to stay in touch to be able to keep their treatment plan in order. That’s one.

The second, I feel it is also important because unless we are in touch with patients, once we can get back, it’s going to again take us a long time to go and build rapport and find them. I think it’s also critical depth. There’s a couple of other things that we’re doing, which I think is very interesting.

Which is basically trying to make use of this time because our patient coordinators in their normal life are always travelling. They’re travelling 20 days, 28 days a month and they are normally working 10, 12 hours a day. We wouldn’t have this time, but we have some downtime. We are using this time to conduct the patient assessment programme. What we are doing is we are calling 1,200 patients only about … the last couple of years and trying to understand, one, their health-seeking behaviour, two, their need and three, what are preventing them or was preventing them to get access to surgery?

Let me give you an example. We are finding some very interesting things there. For example, Vijayawada is one of our sites where we keep going back every year. We have been doing that for the last five to six years. We don’t have a centre there. We go there every year, we do a mission and we come back. What we’re hearing now through our patient assessment which is just midway, is patients in Vijayawada, a lot of them, about 120 patients are saying that they need speech therapy.

We want to use this knowledge to redesign our programmes. What does that mean? I’m already starting to think about maybe a small speech clinic in Vijayawada. We don’t have to mount a full-fledged centre because that’s expensive. It’s difficult to mount, but a small speech clinic is not difficult. We’re already thinking of mounting that in partnership with the hospital when we work in Vijayawada and provide this comprehensive and complete care to patients whom we are taking care on missions.

I think it’s been very interesting, this patient assessment there are a lot of – it’s basically a very bottom-up approach to programmes. It’s not about the deciding which patient needs surgery, it’s what kind of treatment those patients need and then going with it. It’s more of patients telling us what they need.

In a way, I also look at it as patients demanding certain services. I think this whole conversation is going to help us design more targeted programmes which will address these patients’ needs. Again, basically trying to take advantage of the downtime of our patient coordinators who are always running around to get into understanding our patients a little bit.

Laura: That’s so important. I think we’re seeing that in a lot of our foundations. Howard, is your team taking similar steps to really improve the way you’re able to deliver cleft care once it’s safe to do so?

Howard: For sure. I think that Abhishek, India and Operation Smile in Madagascar are trying to take the same pathway now simply because we are also searching a way to develop the comprehensive cleft care in the country. We are working on speech, dental, on psychosocial programmes. We are trying to redefine the whole programme. We’re designing now, but we have nothing structured yet. But we are trying to find a way to deliver the comprehensive cleft care. As I said, we don’t have nothing structured but we want to do it with the safest way possible as we can do with the best resource we have like equipment, human resources and infrastructure.

Talking about resuming surgery: resuming surgery is not our top priority. Our motto is, as I said, the safety of our volunteers and our patients as we don’t have an Operation Smile centre here in Madagascar, all our operational hospital partners are not safe for surgery yet. Many health professionals working too are testing positive.

Unfortunately, most of our volunteers who are credentialed are testing positive or presenting symptoms or are at a higher risk in the hospital because they are in the frontline. We are not ready to start surgery anytime soon. I want to mention again what I’ve said with thousands of cleft cases in the world, we have always focused our time and our energy to organise more and more internal missions, but our main focus this new fiscal year is to try to develop how a comprehensive cleft care should look like in Madagascar.

Laura: Thank you. Before we kick over to audience Q&A portion, Abhishek, did you want to add anything to that, your next steps for resuming care and surgery?

Abhishek: I think the thinking is very similar to Howard what you mentioned because safety is paramount. To me, I think there is two things to consider. One is safety of our patients, of our volunteers, of our staff. The second thing is also the way I’m looking at it is also sustainability, because we don’t want to open up a centre and then again have to close it down after three months because there is a sudden spike in numbers, or because we don’t have the available resources, or maybe there’s not a sudden spike in numbers, but there’s some restrictions on the government because we are not able to move patients. There are a lot of things that we are considering.

First and foremost, like I mentioned, is when you look at India, you have to break down the numbers regionally. For us, that is the most important part because you can’t look at India as a whole, we have to look at it regionally. Places where the curve has started to flatten or there is a plateau, or things are going down, those are the areas where we’re going to start operating first.

A lot of things to consider around that, of course, it’s a given that all necessary precautions in terms of PPE, as well as other protection devices, as well as social distance measures, they will need to be followed. Operation Smile has actually developed a fantastic document. It’s guidelines for foundations to restart programmes, which talks about exactly what’s kind of the PPE we need, how much quantity we need. Of course, it goes without saying that we will be following that, and that needs to be followed.

I think a couple of other things that I have in mind is, one, is mobility and movement of patients, which is very critical because when we start a centre, we are going to have patients, we need to have patients come on a steady flow. Unless public transportation is open and safe for patients, I believe we wouldn’t be able to go back and open up a centre or run a programme.

Second is even if we are bringing patients, which is what we’ve done many times in the past, we may now put them in vans and cars and bring them in. Is there a government restriction of mobility between one district to another district, one town to another town? Those are some things we have to keep in mind.

The third is testing, because India has increased, ramped up its testing capacity quite a bit. Still again, one of the things that we have to do and we want to do is make sure any kid that’s going on the table is COVID negative, so we will be doing a COVID test on them. Currently, the way it works, again, there’s a huge regional disparity on the number of testing and the ability of testing. Kits have been in shortage for a long time in the country. That’s why it’s highly regulated by the government. Again, we are waiting for testing to become a little easier.

Nowadays, results take about 40 to 48 hours, maybe sometimes even 50, 60 hours, too. Again, trying to wait and see, because in some places, the timeline has already shortened, some places it’s already within 24 hours, 12 hours, and you are getting a result. So, trying to figure out all of these different elements before we are able to get back to work. Currently, we are actually looking at starting the centre in Bangalore sometime in August. We took a decision on it last week, but then again, in the last seven days, we are seeing there’s a bit of a spike in the numbers in Bangalore. Actually, again, it’s gone back into consideration.

The way I see is I think that West Bengal, Bangalore, these are going to be some of the places where we’ll start first. But Bangalore is a small centre where we do about 20, 25 (surgeries) a month. There’s not a lot of overcrowding. Durgapur is a bigger centre. But of course, once we get back, it’s not going to be doing huge numbers for the first couple of months. It’s going to be starting slow, getting used to the new reality is the way I’m thinking, because right from our patients to our volunteers, everyone has to get used to it. It’s just a new way of living, I think.

Get there and then slowly increase the numbers at centres. In terms of missions, like Howard mentioned, of course, we are not looking at any international missions this year.

Even next year, maybe toward the financial year, May, June, if possible, we’ll look at the international missions. We are looking at running some international missions in the second quarter of next year. Again, a lot of ifs and buts, it will depend on how things step up.

Laura: Great. Thank you so much. Now we’re going to kick it over to John for our last few minutes here to answer some of the questions from the audience.

Audience Q&A

John: Yes, thanks. We have a question coming from Salma. Howard, I’ll direct this to you. She’s wondering as a high school student, she’s interested in how she can contribute and help amidst the COVID outbreak. What advice would you have for her as a high school student?

Howard: Excuse me, can you repeat the question, please?

John: Sure. The question is, as a high school student, I’m very interested in how you think we can help and contribute amidst the COVID outbreak.

Howard: Okay. As a high school student, I think that what she can do now – she’s from where, please, John?

John: I’m not sure. I’m sorry.

Howard: Okay. As a high school student, first, all she can do is making sure –

John: UAE.

Howard: Where?

John: United Arab Emirates.

Howard: Oh, okay. As a high school student, I recommend her for this COVID-19 outbreak to respect all preventive measures first, because it’s the most important now. Because like that, she can contain the spread of the virus in her country and in her house. Also, getting all information she can (get) and spread it around her, of course, the right message to the right person because this virus is going to change our mentality. There’s a lot of things that we have to change. Of course, there’s a lot of things that we need to consider for the future, and all I can say now is, as a high school student, to respect all preventive measures.

John: Absolutely and Salma also feel free to reach out to Operation Smile UAE and you can inquire on their student programmes and see if there’s any initiatives that they have running as well. It could be a great way to get involved.

Okay, our next question is for Abhishek, and it comes from Linda. She also says this is Linda Bucher, Abhishek, someone that I know you know well, so she wishes you all the best and hopes your family is healthy and safe. You alluded to it a little bit. Is there any type of telehealth activities going on in India or Madagascar? With respect to speech therapy, nutritional teaching, etc.

Abhishek: Okay. Firstly, hello, Linda, hope you are well, and you’re staying safe. Coming to the question, so see there’s not a lot of telehealth activities going on, but it’s more of patient assessment piece as well as trying to staying in touch with patients and provide them the right kind of guidance through those and help them get through this till we get back. In India, there isn’t. Of course, there’s some consultation going on need-to basis in the sense like I was mentioning in terms of the orthodontic treatment.

There are people who already have certain fixtures, and they need to twist this by one inch or one rotation every two weeks, every three weeks. Those are things that we are following up on and we are doing. Other than that, we are in touch with patients through the patient assessment piece, as well as talking to them about this schedule for treatment.

But, no, there’s nothing in terms of speech therapy or nutritional teaching over the phone. I know other foundations in Operation Smile are doing it. I know Nicaragua is doing it. Absolutely. Actually, one of the countries that I oversee is doing it, and I know some parts of Russia. Russia is also doing it. They’re doing speech therapy as well as some nutritional counselling over video calls as well as telephones.

In India, unfortunately, we’re not doing it. We did think about it, but somehow, given the available resources, the restrictions of lockdown, we weren’t able to implement it.

I think it’s a great point, and we already have been thinking about it, but I think you just reiterate that maybe as we start to live with these new realities, that is something that we should consider and start developing programmes and all that. Thank you, but currently, we don’t have anything but we will start thinking more seriously about it and maybe have a programme soon.

John: Excellent. Well, again, I just want to thank everybody for inputting your questions. I want to thank our panelists, Howard and Abhishek, for their time today. Thank you guys so much for joining us and sharing your insight with our audience and with the world. It means a lot to us. Yes, on behalf of Laura and I, we’re signing off for this COVID-19 Conversation, and we’ll see everybody next time.

COVID-19 Conversation: Resuming Surgery Safely

Our promise of improving health and dignity during the COVID-19 pandemic endures. We’re helping frontline health workers stay safe, nourished and empowered to better serve their patients by providing life-saving supplies and equipment, as well as remote training to bolster their response. We’re also providing nutritional assistance, hygiene kits and virtual health services to support people and their health needs so they can thrive. If you can, when you can, help us keep our promise to care for children and create hope for tomorrow.

Now, more than ever it’s our charge to safeguard the health and wellbeing of individuals around the world. We’re building upon our expertise in delivering cleft surgery and care in resource-limited settings as well as our history of improving the health and dignity of those we serve.

That’s why we’re finding the most meaningful ways that we can support people and their health needs in the communities where we work, even when medical missions are postponed, care centres are closed, and the future feels uncertain. It’s in this uncertainty that our swift action is required, and we’re doing everything that we can to help patients, families, and countries as this affects them.

While we’re still unable to provide direct patient care in nearly every place where we work, we’re beginning to resume direct activity in places where health authorities have deemed it safe to do so. In late May, we were able to resume providing surgeries in Vietnam and Italy.

This “COVID-19 Conversation” featured a live question-and-answer session on the topic of resuming surgery amid the pandemic with Dr. Ruben Ayala, Operation Smile Chief Medical Officer; Dr. Domenico Scopelliti, maxillofacial surgeon, Operation Smile Italy and Smile House Rome; and Viet Nguyen, Regional Vice President of Development, Operation Smile Vietnam. The session was hosted by John Streit, our managing editor and writer; and Laura Gonzalez, our digital content manager moderated the audience’s chat and questions.

Event Transcript

John Streit: We’ll go ahead and get started. I’m John Streit the Managing Editor and Writer for Operation Smile and alongside my colleague Laura Gonzalez, a Digital Content Manager. We spend a lot of our time following our COVID-19 response and, now, our phase back into activity around the world very closely. We’re really pleased to bring our panellists to you today for a really great conversation on how we’ve been able to resume surgeries safely in both Italy and Vietnam.

We’re really excited about that and to understand the level of undertaking that has transpired over the past several weeks to bring people to surgery that they need and deserve. My colleague Laura will be moderating the chat portion. Do you mind giving people a heads-up on how they can engage?

Laura Gonzalez: Sure. Hi, guys, and thanks again for joining. There are two options for interaction. There’s the chat and then there’s questions. I encourage you to input in the “questions” category and then at the end, once we hear from Ruben, Viet, and Domenico, we’ll go ahead and have a live Q&A portion.

John: Awesome. Alright. We’ll dive right in. I’d like to introduce our panellists today.

We have Dr. Ruben Ayala, Operation Smile’s Chief Medical Officer. Ruben is a physician and public health specialist from Panama with 25 years of experience with Operation Smile. He first became involved with the organisation as a student volunteer and has served in many programmatic roles before reaching his current position as Chief Medical Officer.

He is also the current President of the Permanent Council of the Global Alliance for Surgical, Obstetric, Trauma and Anaesthesia Care and represents Operation Smile in the Global Initiative for Children’s Surgery, the World Health Organization’s Global Initiative for Emergency and Essential Surgical Care and the United Nations Economic and Social Council. Welcome, Ruben.

Dr. Ruben Ayala: Good morning. Thanks for the opportunity.

John: Absolutely. We have Dr. Domenico Scopelliti, Maxillofacial Surgeon with Operation Smile Italy, and Smile House Rome.

Dr. Domenico Scopelliti: Hi.

John: Hi, Domenico. Dr. Scopelliti is the Director of the Maxillofacial Surgery Unit at San Filippo Neri Hospital in Rome. He has served on over 40 Operation Smile medical missions and also serves as a Director of Smile House Rome, a comprehensive cleft care centre. He has served as the president of the Organising Committee for the Roman Days on Maxillofacial Surgery, the President of SMORRL Hospital Medical School in Rome, Lazio District, and the Italian Society of Cleft Lip and Cleft Palate and is a select reservist of the Italian Navy. Welcome, Domenico.

Domenico: Hi, everyone.

John: We have Viet Nguyen … the Regional Vice President for Development and the Chief Representative for Operation Smile in Vietnam. He holds 24 years of experience serving Operation Smile in different positions and capacities and plays a vital role in the growth of the organisation in the Asia-Pacific region.

He’s a long-time member of the American Chamber of Commerce in Vietnam, and currently is serving on boards of many Vietnamese student groups. Welcome, Viet. Thank you for joining.

Viet Nguyen: Hi, everyone. It’s a pleasure being here with you guys today. Thank you, all the way from Vietnam.

John: I thank each of you for bringing your insights and expertise to the table, and thanks to everyone who’s joining us today. We’re looking forward to this. We’ll dive right in. Ruben, our first couple of questions are for you.

In March, Operation Smile made a decision to postpone surgeries amid the COVID-19 pandemic. Could you tell us more about the factors that led to that decision? I know it was a very fluid and complicated emerging situation at the time.

Ruben: Sure, and to preamble that answer, I will just go back to two areas that I’ve seen historically in Operation Smile that made me really believe in the heart of the organisation. One is the utter commitment to offering help to people with remote access or without the ability to reach that care. The other one is the huge safety culture that the organisation holds around the world, and a commitment to implementing that safety as we roll out any interventions.

When we had to make the decision to halt activities, it was a difficult decision from the sense of we realised that we’re having to stop things that people receive that they believe, and we believe, are hugely impactful on the lives and wellbeing of the children and communities. At the same time, when you look into the safety aspect, it was almost unavoidable. We felt it was the right decision at the time. Some of the things we wanted to do was to definitely protect our patients, our volunteers, our staff, our partners, and our communities from the potential impact of COVID-19.

We saw the deteriorating epidemiological profile. The virus started to spread at a rate that really opened our eyes and it was right in front of us. We, normally, in order to achieve the goals of taking care of hundreds and hundreds of children, we end up mobilising a lot of volunteers from the countries and from different parts of the world. We end up mobilising communities and families to places where we can converge and offer intervention.

We realised that doing that, in the midst of the potential threat of an outbreak at that time, wasn’t probably the right thing to do. We did not want to be responsible for introducing the virus either into a country or in the community, or worse, in situations on the country side, where they are already feeling the extent of the virus. The other part was the environment of the agent – the symptomality of the virus from what was originally observed in China and as it spread to Italy, and other places.

Also, this was a new thing, this was a novel virus. The response from different countries and governments and leaders was fluid. They were changing situations, where countries deciding on responses with governments restricting travel, restricting specific transport for specific countries or populations, the way in which the quarantines were being put forward for those with either symptoms or potential exposure, which made us really believe that it was going to take some time to have a cohesive approach towards prevention.

Ultimately, it’s just a desire that whenever we work with people in the communities to take care of children, we realise that we’re coming together and using our time, our talents, our resources to do this together. We realise that countries and communities were now having to face this new agent. We did not want to overburden or disrupt efforts in the preparation or response to COVID-19.

John: Absolutely. I know safety is one of the major underpinnings of this organisation. It completely makes sense that we would want to contribute to that, how we can in the midst of the pandemic. Shifting back to the topic of cleft surgery, obviously, we want to keep people safe and prevent the spread for the virus, but cleft surgery is essential for those who need it. Could you speak more about why cleft surgery is essential? What factors are we taking into consideration when determining how we can resume surgery safely while COVID-19 is still out there?

Ruben: Let’s just report from the fact that (since) the initial decision to stop up until this point, a lot has happened in a very short few months, which seem like an eternity to so many people, a lot has happened. There’s now a lot more awareness and knowledge about COVID-19. There’s also a greater awareness of what we don’t know, and we’re actively trying to get answers every day, and even greater connectivity between providers who are trying to come up with solutions to some of the challenges that are posed.

Our initial response, we believe fervently that it was the correct one. We believe that the conservative approach to even the resumption of activities is still the correct one, but let’s also put things into context. This apart from the fact that the choice to not provide care to people, either surgery or comprehensive care, is not a benign one. Children are still suffering because of it.

We have to start asking the question of how much of that suffering can we overcome, or how much of that suffering can we alleviate in the short, middle and long term in the midst of challenges that COVID-19 poses to the world? The reality is that the longer we wait, the longer more children are going to have difficulty eating, speaking, there will be issues in their growth and development.

We also need to avoid the suffering that might come from issues such as malnutrition and all that it brings for children who are suffering from cleft lips and palate. The constant inner ear infections and upper-respiratory issues, stunting in growth – there’s a plethora of things that, in the short term, you can probably say, “Hey, let’s keep this on time.” Over time, the longer you wait, the longer you miss the opportunity and truly help and the more likely you are to perpetuate the negative impacts of their suffering.

You’re going to have to weigh the pros and cons and really start to think of what are the things that you can do. We need to step back from the all-or-nothing approach to one that is a bit more based on the knowledge that is constantly evolving and the awareness. Today, we have the ability to really start looking at the epidemiological data that is available for countries, provinces, regions and communities. We have the ability to look at the systems that have been able to be put in place to track and trace potential people exposed to the virus.

We have the ability to understand which areas, countries or communities have the ability to test and match up to the epidemiological profile of those communities and understand the predictive value of that testing. We have the ability to understand now a bit more about the ability of different countries to cope with an emergence, to cope with the potential resurgence, and whether our interventions do not take away providers from a potential necessary response.

We also have the ability to continue to strengthen our partnerships with local entities, ministries of health, departments of health, members of the private sector, members of the civil society to figure out a way forward. We also now have had a chance to look at human resource availability to offer assistance, and to offer guidance and support to our foundations at the local level and to get feedback from them as they’re dealing with the challenges.

There’s also the ability to provide ongoing surveillance. As we start some activities in different places, if we are committed to the surveillance, and we see some challenges coming our way, we should scale back just as we did before, having a very comprehensive review of the evidence for the improvements that we can put forward and are applicable in the context of the communities that we’re working with.

All that to say is we can step back from the all-or-nothing response, start to understand what is happening in a specific area and use the arsenal of knowledge, of the ability to respond, the ability to prevent, and the resources that we can put forward to make a decision of how much of the suffering we can tackle in the short, middle or long term.

John: Excellent. Thank you, Ruben. That leads us right into Viet, and in Vietnam, where we’ve been able to resume surgery much further ahead of the curve than we would be able to in many other countries. That relates directly to all the factors that Ruben was just speaking to. Viet, in May and June, we provided surgery for 202 patients in Vietnam. That was our first surgical missions back since postponing, still, to this date, almost all of our programmes around the world. You were the first ones to be able to get back in and provide surgery for children in Vietnam. We know you worked closely with the Ministry of Health to prepare for the mission last month. What were the factors that led to the decision to be able to resume surgery?

Viet: Well, thank you for your question. This is a great question. As you might know, we just resume our normal surgical activity about a month from now, a little bit more than a month. There was about more than 200 surgery that our medical team in Vietnam has been able to perform and bring in positive changes to these patients and families. To be honest with you, the first six months of, we call the COVID years actually is very challenging for all of us, it’s not just for us here in Vietnam. I’m sure as for many of you on the other side of the world as well.

I think the reason we were able to step back and resume our activity in the country, there’s different factors. I think the first factor that would allow us some confidence to get back into this work is we’ve been seeing a safe environment in the country. As you might know that in Vietnam, as of today, there’s only 335 positive cases in the entire country since the pandemic was started, no deaths. There’s no new cases in Vietnam for the last 60 days, which is close to two months.

Then, I think that the Vietnamese government, plus the Vietnamese people, who are actually using a lot of control measures. We immediately closed the borders, preventing people from flying from overseas into the country. We also made sure that everyone who arrives in Vietnam takes 14 days in the camp for quarantine and they also have to self-quarantine for another 14 days at home. Everyone has to do the test for the symptoms of COVID-19, in case they have been in contact with other positive cases. I think the first factor that actually allowed us to go back and resume our work is actually that we feel that we now have a safe environment in the country.

The second factor is, I think, regarding the way that when the COVID pandemic happened, it changed everything in the country. It changed the way the world is thinking about an epidemic. It changed the way that people were working daily. It changed our habits. It changed everything.

I think that also leads to the fact that every single hospital in the entire country, these 1,400 hospitals in the entire country, had to change. Instead of just letting people go in like normal, now we have to set up the isolation areas, it’s a must to provide the PPE for the doctor, the medical professionals working in the hospital.

I think that’s required prompt action from every hospital in the country and also prompt action from everyone who actually goes into the country. That means it creates a more than safe environment for us to go in if we resume our work with our partner hospitals in Vietnam. Some of the hospitals actually as requested by the Minister of Health of Vietnam, they have to turn the hospital to be ready or to be the COVID-19 hospital which is an additional requirement from the health sector or the Ministry of Health of Vietnam.

The third factor I think that’s also allowing us to go back and work actually is, we strictly follow all the guideline from the Ministry of Health of Vietnam. We’re hearing it, seeing this day-by-day, depending on the situation, how has it been progressing. Then the Ministry of Health of Vietnam will allow us and turn on the green light for us to go back and resume our work. That’s how we were able to do the very first mission in May in Hanoi. Then because of all the successes that we were able to achieve for that mission, including the safety measurements, now we were allowed to continue with our second mission in Ho Chi Minh City.

It led to the fact that we were able to provide more than 200 surgeries for these people and (will) continue to do more in the next couple of months. The third reason I think is that actually from the Operation Smile perspective, also, I think that because the first six months, we would not be able to do anything. We focused on being safe, staying well, and taking care of ourselves, and that sort of thing.

We foresee that the demand for this sort of surgery is still very high. Particularly, for this time of the year, it’s the summertime, so people do not need to go to school, they’re going to finish the school year very early. People keep calling to our hotline and making sure that they ask when we’re going to be able to resume our surgeries and our daily work. We consult with our Ministry of Health of Vietnam and our partners to make sure that we’ll be able to bring them back.

Overall, I think that there’s a couple of factors that we can simplify. First of all, it’s positive progress. We feel safe. We strictly follow the guidelines, we’re making appropriate decisions. We’re actually doing a great collaboration with our in-country partners and also with Operation Smile in the U.S., and we did it at the right time. That’s all the factors bringing us back to resuming our work in Vietnam.

John: Amazing. Ruben, are there any countries where we’re looking at resuming medical or education programmes soon? Is there anywhere similar to Vietnam that we’re looking at?

Ruben: Yes. China is another example where the government of Yunnan, which is a province in the south-west part of the country, has requested Operation Smile to restart its work with additional measures in place. They haven’t had a COVID case in over two months other than what they would consider an important case. Their schools are open, they’re coming back to the normal activities.

Yet, when we look at China, we watch the news, and you see that there might be some activity in Beijing right now which raises concerns of the potential respread of the disease, which does make us really evaluate. At the same time, we put things in perspective, Beijing to Yunnan, we’re talking about a distance of about 1,400 kilometres, which will be the equivalent of someone from Florida flying all the way to Bogotá, Colombia.

We do have to acknowledge that there’s potential threats, but we also can continue conversations with that ongoing monitoring on what can be done in a place where there hasn’t been contagion of any magnitude and people are coming back and believing that we have potential ingredients to resume that activity. That’s one. Morocco has resumed their activities at their centres – non-surgical activities in a very step-by-step version following some very specific protocols and quite strict guidelines imposed by the government, as well.

If we look at the epidemiological profile, there are no higher in cases – they are very close in cases to the (profile) of Australia, for instance. In Australia, if you know, they have a bubble between Australia and New Zealand of travelling and communication. We have other countries such as Guatemala, Dominican Republic, Nicaragua and others who are looking to reopen their centres in the next few months. We’re having really careful and thoughtful discussions about the projected activities, the level of activities, and how that may be impacted given the human resources and the need of the patients, the setup of the epidemiological profile of the places where they’re located and much more.

Again, the common theme is we’re hopeful, and we want to reach our children because we’re committed to them and to their wellbeing, and at the same time, the safety component is critical for us. The same things that made us, at some point, halt activities are things that we will continue to keep in mind even as we look to reopen some of these activities as well. We are responsible to the communities and the countries but also responsive to the needs of our children.

John: Awesome, Ruben, thank you. Domenico, when COVID-19 reached Italy, I mean it was a really hard hit for your country, as we all know. And I know it deeply impacted the care you were able to deliver at the Smile Houses across the country, all four of them. Tell us more about how COVID-19 impacted that delivery of care when it first reached those really peak levels?

Domenico: Yes. You can imagine that here in Italy, we had to face the pandemic even three or four months before the western countries and maybe at the same time of some eastern countries. The impact in Italy was unpredictable, because we were not ready in terms of facing the emergency. That time was a very dramatic event that obliged us to immediately, in two days, reach the total lockdown of all activities. The public health system allowed us just to continue the emergency surgeries and other services that are not possible to postpone.

The root activity, including the activity that we’re running with the project that was Smile House in all the Italian territory, was blocked totally for two months. We have to take a decision, because as an organisation that makes a programme with the public health system, we have two options. Rest hands-on and wait until the finish of lockdown and suspend any kind of check-ups, but it’s not possible because you can imagine, it’s not just surgery that we provide, but the entire path that follow the kids from the pregnancy until the end of growth. We take the responsibility of a wide range of patients and the families that we have to follow.

We took the decision to support the emergency of the pandemic even in the hospital where we have Smile House. Providing any kind of PPE, supporting the Civil Protection Agency with a donation and supporting our staff or volunteers that suddenly were involved in treating the COVID infection. The problem that we have, on the other hand, is that we provide the other kinds of activities, so video calls for speech consultation, prenatal and pregnancy support for the family, and supporting our volunteers and professionals involved in the public health system in Milan, Rome, Vicenza and other cities.

On the other hand, we will help the doctors that are not routinely involved in emergency with training, because they have to face it, to do something that they are not able to do in their ordinary activities. We organised a training course online on the basic treatment of patients affected by COVID that was dedicated to volunteers and was online courses that benefited over 200 people.

We also did an international webinar on treating patients with anti-thrombotic disease for Operation Smile with our volunteers, Professor Salvatori from the University of Sapienza. It was an experience that was benefiting many, many, centres because, as they discover the pathogenesis of the COVID, there was a dramatic change in treating those patients.

We also did a teaching course for the European Association of Medical Students, just training and to maintain the attention on the activity of Operations Smile. And also, five webinars on orthodontic care … for cleft patients and other topics that our volunteers are interested in. For us, it’s very important to continue training people and teaching them to create this national network that supports the Smile House project in the entire country.

The criteria, at that time, was just to have the time to realise the second phase, because during the emergency, we are projecting how to continue, because we imagine that the emergency will be over not soon – but we hope it will be soon. The project here is how to face a journey before there’s a vaccination, how we can run, how we can restart. I, very often, use a term of navigation, because when we describe our journey, imagine that we’re going to the point A to the point B and the COVID pandemic moved our boat to point C. The route is totally different. We have to project another route. We have to provide another way to rethinking the entire path to arrive to the point C. That is very important, because it’s not a simple restart.

We have to consider a new way to face the problem. As Ruben mentioned, we have to be more careful in safety, considering the medical legal consequence, if we spread the virus thanks to our activity. We have to protect the entire path and protect the patients, the family and also the medical staff. We have to create new criteria.

We have to respect our job, because we can’t wait such a long time, because everyone knows that if you treat patients with cleft deformities, we have to respect them and to be on time. Timely surgery is very important, because if you do the right job at the right time, you reduce the risk of having functional consequences. It’s important to respect that time because if we promise to operate all the newborn kids in the first years of age, we have to maintain our promise in any way, because otherwise we’re going to have consequences.

When we re-project the new activity and restart with the activity, first of all, we have to block any kind of possibility that the virus comes in. We have to imagine a totally COVID-free activity as much as possible. Obviously to protect the 90% is very high aims that we would like to achieve. But normally, we can protect, because it is in the experience of hospital and that’s treating patients with infection that there is a way to protect the people that work there and to protect the entire path that is selected, the area where the virus cannot spread out, cannot run away.

First of all is creating a specific area, COVID-free. That means every kind of test has to be performed outside of that area. Testing people, the general criteria even in the peak of the epidemic event, or in the phase two. The important thing is to avoid, as much as possible, the possibility of (the contagion) in the safe area. That means that testing has to be performed before. In the criteria that suggest, all the epidemiology suggests that to test, tracing, and treating, and all these things have to be performed before the access of that area.

That if you test, reduce the risk of the people coming in with high potential infection that can be dangerous for the entire area. The second thing is to change any kind of DPI. The people that come from abroad and try to have access to that area, and normally even in this time, comes with their personal PPE. That means that they wear gowns or mask that they come from the home, but they can be contiguous in that journey that came from the house and before they have access.

We do the test, change completely … and we give them our personal PPE, and we save in a specific plastic bag all their personal items, their personal belongings, and any kind of things just to reduce the risk of contagion with the items that they carry before to have access. Then they have access in the waiting area, and one by one, have access to the ambulatory services.

This is for the ambulatory services and there’s two different ways to go in and out, so it’s not possible to go out from the same access where you come in. This is a different door or entrance, and the way out allows us to reduce the risk that you can bring out and in people. Even the doctors are obliged to do this kind of access. For the medical staff, they have to change every time their personal protective equipment every time they change patients. It’s very important and even also the decontamination of the entire area is provided by the hospital, but there are personnel that are dedicated every time the personnel changes to provide another decontamination procedure before having access to another patient.

For the surgery, the fix is a bit different, because you know that there is scientific proof that if you treat patients, even asymptomatic patients but they’re COVID positive, the surgical risk is very high. For all the patients that are going to undergo surgery, it will require a negative swab for patients 48 hours before the surgery day. We prefer to have the patients the same day as we have a negative results of the test in the ward. That allow us to have total control, because if the area is safe and the patient is negative, the access is correct.

Then the serological tests has to be performed. Even for the parents, the one parent is allowed, or the guardians, but just one (has the test) performed (because) it’s faster to have results. We oblige even to the parents to have the serological test before they have access to the hospital. Even during the recovery time, we oblige all the people to leave personal clothing and items in safety bags, so nobody has the opportunity to bring their own items, their personal belongings, into the area.

Giving personal PPE for patients and the other person and maintaining always the social distance even in the ward. In the ward, where we have normally four people, we have just two. In the rooms, when we have access to eight people, we accept maximum three or four. That is very, very important, because we consider even if it’s safe and we follow any procedures for decontamination, it’s very important still to maintain the social distance.

For the medical staff, we are adopting (safety measures for patients receiving other kinds of surgery) that require the use of drills or cutlery or other things that they produce aerosol. Aerosol enormously increases the risk, even during the intubation of the patient at the time at the start of a surgery. Even during the surgery …

There is a specific helmet that was invented, first of all, from the orthopaedist that you can see (here). This is a specific guideline suggested for anaesthesia and for surgical staff, plastic surgical staff, maxillofacial, are produced by different companies. With these helmets, is this very full head-cover system with active air filtration to protect the clean room and provided the use of comfort.

It’s very comfortable for the surgeon to wear this helmet, but it’s very safe, because we don’t have any kind of contact of external ambience and protected totally from any kind of aerosol produced during the surgical time.

John: Wow, it’s amazing.

Domenico: Yes, this is very very useful. We have another personal PPE that I would like to share with you. It was invented for NASA, for the (International Space Station), and produce (hydrogen) peroxide and give a decontamination area 90%, 90% of decontamination from any kind of bacteria and virus. This is possible, that can use as a personal, you can wear and create a free zone, a safety zone of five cubic foot excluded zone around the head and protect and increase the protection of the normal mask. That is very usable.

Under this helmet, you can wear any kind of mask, because you are totally surrounded. We just use, as you’ll see, a normal protective mask. You can also choose to not wear anything because you are surrounded by a shield that protects you.

John: I think it’s really great to see that you’re leaving no stones unturned in terms of safety for our patients. I think when we say that we have this commitment to the safety of our patients, their families, our staff and volunteers, I think everything you’re speaking to just symbolises, shows and demonstrates that commitment, Domenico. I’m sorry, I hate to interrupt, but we do need to move things along a little bit. Is there anything crucial that we’re, we’re missing from the things you’re describing here?

Viet: I could add three small things that I think that actually is a great learning for all of us, it’s not just for Vietnam particularly. I think that, we’re thinking making early and decisive actions, taking early and decisive action is one of very important thing. As far as you know, when the very first cases was happening in the country, the government just really considered the COVID-19 as a major threat even before the announcement from the WHO.

I think that’s one of very good learning for us because that’s how we were able to control that a little bit earlier than others. They follow with different restrictions, a steering committee was set up (and created) sectoral responses plans … to cope with the COVID-19, so that’s the first thing.

The second thing, the learning lesson for us, it’s that we have a capability to verify the target and make it very serious without an exception. Any patients that contaminated with positive COVID or people in the same contact with COVID-19 patients will be immediately quarantined. All the treatments, actually, as of now are still provided free by the government. We set up point of entries for borders, airports … I think that we identify good targets and we set serious restriction without any exception.

The third thing is pretty much related to Operation Smile, I think that for the first time since COVID-19, you see people work together. Shoulder by shoulder, side by side to treat patients. All the doctors, regardless of where they’re from, what kind of specialty they are, once they get into the hospital, second to the situations that treating the patient with COVID-19, they treat them with dignity. They’re working side by side, working so well together.

They all see the patient that they never met. It’s a good reflection of the work that Operation Smile does, not just for Vietnam, but many other countries of Operation Smile around the world is we also would like to treat our patients, our children, people we’ve never met, but we treat them with dignity. We treat with the best service that we offer, with a good standard that the organisation has.

I think that we underrate the fact that by working together, we will be able to make a difference. By working together, by involving people, we will be able to bring in and creating more miracles. That’s one, the reason why they are pushing Operation Smile in Vietnam, into the states that we have to work with our in-country partners and key stakeholders to resume our work as soon as the COVID-19 situation is getting better. That’s led to the fact that we were able to do the very first two mission in the country. That’s a good lesson learning for us.

John: Awesome, thank you, Viet. Ruben, one more question for you, and then we’re going to kick into the Q&A portion. We know that around 70 missions were postponed and that led to just under 10,000 patients waiting for surgery. How do we evolve to address the growing need moving forward? How are things going to change and how are we going to pivot to be able to, one, not only keep our promise to each of those patients, but also to be able to continue our work into the future?

Ruben: That’s the challenge, right? I equate this to trying to land a plane on an aircraft carrier in the midst of a bit of a stormy ocean. You’re going to have to really adapt and become very, very innovative and keep a huge amount of coordination and communication. If you hear any of the statements from Dr. Domenico Scopelliti and from Viet, you will quickly realise that even resuming activity does not absolutely equal business as usual.

Domenico looks like an astronaut. He might as well be getting ready for docking to the International Space Station versus doing surgery in that picture that you showed. The things that led to Vietnam, even being able to do that, were pretty significant. When we look into the future, how are we going to tackle the huge amount of need out there that is now getting backlogged?

I got a few things come to mind. One, because we had to realise we’re going to have to make even bigger investments. We’re challenged to acquire more resources because I might not be able to get our teams with a spacesuit in a low middle-income country setting but we do have the responsibility to offer them with protective gear that’s required for them to do safe work and to remain safe themselves. That requires additional investments along with the plethora of other interventions and coordinate activities that we’ve mentioned before.

In terms of the innovative approaches, even the basic processes of offering care and standards now have another layer of how to do all those things and what guidelines can we follow to and what technology can we use to offer care in the midst of COVID-19. Operation Smile has this very, very robust Global Standards of Care, very, very detailed policies and procedures, and on top of that, we now have to create the guidelines that will allow and give answers some of which Domenico has been in a very detailed way of talking about, as you showed in the diagram of how they’re rolling out interventions in Italy.

There’s a greater number of partners and hospitals with whom we can engage. We’re going to have to figure out a way to turn the equation of one plus one equals two into one plus one equals four. We’re going to have to figure out a way to make sure that every investment we’re making to take care of the children also as to the strengthening the health system. What can we do as we take care of children, increase the preparedness and the ability of respond that hospitals and entities have with investments in equipment and access to supplies and better access to training.

How can we use technology the same way? I don’t know, 10, 15, 20 years ago, we wouldn’t be talking the way we are talking today, but we have the ability to use technology to still reach out to patients and connect with them and offer ongoing assistance in specific disciplines that might not require a physical intervention at a given moment in time. It used to be that this benefit will only be in low resource environments. Now we see that in low-income countries, a lot of our patients have phones in a way that they didn’t have before.

We now have access to the villages and the communities that are remote. How can we continue to engage with them? Better coordination between all partners of civil society as different organisations are focused on different activities and different goals. We have to be talking to each other and working with the hospitals that are our partners to better align the sequence of interventions that we offer and minimise any potential disruption out of having four or five different agendas that are integral to one partner.

We have to have a very strong relationship with the health department and our ability to connect our activities with the epidemiological surveillance of the entire country or region and even outward in areas where there’s a need, and we might be able to offer some assistance.

You can keep going: community awareness and response. A lot of us, when we talk about care immediately it gravitates towards happening to the hospital, but care can happen at the community level. It starts with education and spreading really good scientific-based information, factual information that can be understood in a way that that can be understood by the communities to keep themselves safe or to know when to actually seek care. We can use TV, radio, phones, social media to continue to coordinate with health workers and community leaders to prevent some of the hardships of COVID and prepare for the goodness of the interventions we offer.

Anyway, I can keep going. At some point, we hope sooner than later, vaccines will become available. When that comes, what is the size of the programmes that we can put together that would allow for us to still take care of the massive need with high quality, with great safety while we’re minimising the potential spread of an illness like the ugly one that we’re dealing with?

A whole world ahead of challenges, but if we focus on that commitment to children, we would unavoidably become really innovative in how we address the challenge. We look forward to partnering with other organisations, to partner with governments, to partner with private entities, private to civil society and especially with the communities and the families and most importantly, the patients to see a way forward and an opportunity for all.

John: Awesome. Thank you so much Ruben and thank you to Viet and Domenico as well. We just so appreciate your insights and expertise and lending them to us on this call, this virtual event today. We’re going to go ahead and roll right into our Q&A portion. I will let Laura take over from here.

Audience Q&A

Laura: Thanks John and echoing the thanks to you guys, our panellists, as well. A few folks have asked, “Will volunteers who come to medical missions be required to quarantine for 14 days before starting that mission?” This was from Sarah, who I believe is from Vietnam, then also Diana. Maybe Viet, on the missions that you hosted, were the medical volunteers required to quarantine beforehand?

Viet: As of now, with the restriction from travel and everything, the mission we’ve been conducting is pretty much a local mission type of thing. We’re using the in-countries medical volunteers, so they don’t have to be in the 14-day quarantine because they don’t travel. However, they have to strictly follow all the guidelines and the restrictions from the hospital and also from the Ministry of Health of Vietnam.

For example, the very different thing that we have to do right now is if, in the past if we do the mission, we will gather about 100 patients and families. There’s few hundred of them at the hospital. Right now with the situation, we’ll only be able to bring in each and every day about 10 to 20 patients to the hospital every day. We have to do the screening process as usual, more time, but actually that’s a very good way for us to bring the safety to our patient, family and also to our medical volunteers.

We tend to use the medical volunteers. In the past we bring in a mixture of volunteers from different hospital in the country. As of now we tend to use a one team from one of that hospital only. Then we’re also asking people who actually follow to the hospital they need to do the travel history the correlations even within the country, so we know where they’ve been to. Then they have to declare in the form.

Right now, you even download the app and you can do it from your phone as well. The hospital requires you to wear masks and keep a minimum social distance with people. As of now, you don’t have to be entitled 14 days of quarantine unless you travelled from overseas into Vietnam. We’re not fully open yet. Just for a few cases that they come in, they will have to do 14 days of quarantine, and then also follow another 14 days of stay-at-home, quarantine at home. For the local mission we’re using our 100% of our local medical volunteer and professional so you don’t have to be doing that.

Laura: Thank you Viet. Then Ruben, I’m going to direct this one at you. This is from Ricardo, a paediatric intensivist in Brazil. He’s wondering about the basic life support and paediatric advanced life support credentialing process that all Operation Smile volunteers must have. He says that in Brazil and other Latin American countries, this credential can be quite expensive. Considering that all of the missions for this year in Brazil and potentially until January 2021 in Brazil will be postponed, will there be changes to the volunteer credentialing process when we are able to resume surgery or can you speak to that topic at this time?

Ruben: Yes. That’s great, Ricardo, thank you for that question. A couple of things. We’re having certain communications with the American Heart Association as one of the authorised entities to roll out the training. We realised that if we’re looking at the American Heart Association, they have given us an effective way of extending the credential period for volunteers who already have the credentials.

The whole purpose is to maintain safety. I think that if a year from now we were to able to restart and we haven’t been able to offer the maximum amount of training certifications that we had, that we normally would and we would have to, A, look at the risk of those type of gatherings and training but also, B, be really aware of the historical pattern of performance of some of the incredible leaders and volunteers that we have around the world.

If we have from anaesthesiologist or intensivist or people who have performed outstandingly as so many of them do, to tell them you cannot take care of a kid because you don’t have this clause at this stage, it becomes another challenge, another barrier. Remember that when we instituted PALS and ACLS and BLS as a safety measure were in excess of what was already being required by the current certifications and training that all these providers have.

I would be hard-pressed to tell someone like Ricardo that you can’t help us take care of a kid who’s in need because I can’t offer a paediatric advanced life support certification. We have to really, really be thoughtful and at the same time as an organisation, we would have to recommit to offering Ricardo and others the opportunity to get certification at the earliest possible time.

I hope that answers it. Again, there’s some evolving and being trained but some of this knowledge through the certifications gets fine-tuned but as providers, we realise that experts like Ricardo and others are very aware of this knowledge and this knowledge that doesn’t go away.

Laura: Yes. Ricardo has said, “Thanks, and send my best to Ruben and Viet.” I think you answered his question. Following that similar tune of events, I just wanted to again thank you, Ruben, Viet, and Domenico for lending us your expertise and for sharing the learnings that you’ve had from resuming surgery and patient care in your countries. To our audience, thank you all for joining. We will be sending a recording of this event in the next day or two. As always just reach out to us if you have any questions. We’re here to help. Anything else to add guys?

Ruben: No, just a huge thanks to you.

Viet: Yes, we want to thank everyone for joining together on this.

Ruben: Yes, and for accompanying us on the journey of trying to figure out a way to going back to taking care of children.

John: Absolutely.

Laura: Perfect.

John: Thank you so much.

Laura: All right. Thank you, guys.

Viet: Thank you very much, you guys.

Domenico: Bye.

Love Breaks Down Barriers

Editor’s Note: The Philippines holds a special place in the history – and future – of our organisation. It was there that Dr. Bill Magee, a plastic surgeon, and his wife Kathy, a nurse and clinical social worker, became inspired to create Operation Smile after witnessing first-hand the dire need for life-changing cleft surgeries while working an independent volunteer medical mission in 1982. Unable to provide surgery for so many children due to lack of resources, the Magees promised to return. We’ve been going back ever since. As we work into our 35th year, we’re highlighting the birthplace of Operation Smile with this four-story series. This is the fourth story.

Remedios does the laundry while holding her 2-year-old daughter, Hazel, in her arms. She hangs wet clothes to dry on a clothesline between two small houses in their village.

This is Bantayan Island, Philippines – an island that was a holiday paradise for tourists before Typhoon Yolanda destroyed nearly all of the buildings here in November 2013. Although it’s been years since the storm’s passing, the island is still struggling to regain its former reputation as a tropical vacation destination.

The island, surrounded by beautiful white sand beaches, has a population of about 125,000 people, and many residents make their living by fishing and farming. In the wake of Typhoon Yolanda, irregular and low incomes have made daily life difficult for many.

Bhoniemae Alolod Malaga was born on Bantayan Island and knows its people well. She and her husband, Kristian, run the small non-profit organisation Abounding in Love, which provides transportation, lodging, healthy food, medical checkups and other prerequisites for impoverished people affected by cleft so they can receive free, safe surgeries provided by organisations like Operation Smile.

Photo: Jörgen Hildebrandt.

Hazel is one of these patients. She was born with a cleft lip and a cleft palate.

Hazel’s father is a fisherman and Remedios stays at home to care for their large family. Sometimes, the mother of nine children makes extra money by doing laundry for neighbours. The family, which makes less than $6 per day, could never afford to pay for transportation to get to a hospital in Cebu City – a few hours away by ferry and bus – let alone the cleft surgeries their daughter so desperately needs.

“We wanted to cover the whole island to find these children, so we do everything we can do to locate them,” Bhoniemae says. “What we do is put posters in every municipality, and once they contact us, we personally conduct a home visit to those patients.

“We often find that these children suffer from malnutrition and other medical conditions, so Abounding in Love provides medication and proper nutrition to get them healthy enough for surgery.”

Bhoniemae Alolod Malaga. Photo: Jörgen Hildebrandt.

Abounding In Love’s critical service to Filipino families like Hazel’s began in late 2011, when American businessman Arlen Van Os of Michigan first saw a photo of a distraught, elderly woman holding her grandson, Sam, who suffered from a cleft lip. Van Os learned that there were no plans for Sam to receive free surgery from another cleft organisation, as the family did not have the money to afford the ferry and bus rides to the hospital in Cebu City from Bantayan Island where they lived.

Van Os had fallen in love with the country and its people after a business trip related to his Michigan-based industrial finishing company, Serviscreen. Alongside his son and daughter-in-law, who is Filipino, Van Os founded the web design company Avare in Cebu City about seven years ago and started to organise annual Christmas parties for children and families there.

It was after the 2011 Christmas party that Van Os learned of baby Sam’s plight, and he was moved to help. Van Os decided to pay for food, lodging and transportation for Sam and his family to reach the hospital in Cebu City where the free surgery was offered. He enlisted Bhoniemae, then a manager at Avare, to administer the goodwill project.

Photo: Jörgen Hildebrandt.

Sam received surgery, and it wasn’t long before they found another patient, a teenager named Rosalie, who they decided to help in the same way.

“Word spread from family to family that some strange Americans and Filipinos were willing to help them go to the city for cleft surgery, so we began donating more and more of our time to bringing families for surgery,” Van Os said. “We decided to call ourselves Abounding in Love, from a Bible passage describing a person who has so much love they cannot contain it.”

When Typhoon Yolanda struck Bantayan Island, Abounding in Love had assisted 21 children and their families. Tragically, most of their homes were destroyed or badly damaged in the storm. Abounding in Love sent in food and water before organising the construction of 16 new homes for the affected families. Seven months after the rebuilding project concluded, Abounding in Love met and assisted the Operation Smile team at a Cebu City medical mission.

Photo: Jörgen Hildebrandt.

The experience gave the newfound charity a heightened sense of conviction and purpose.

“We decided to shut down our website business and devote our very small-but-capable staff entirely to the work of Abounding in Love,” Van Os said.

With Bhoniemae and Kristian running the small non-profit, Abounding in Love hopes to even reach out further into the remote parts of the Philippines. As of the publication of this story, they have helped 333 children to receive more than 340 surgeries.

Photo: Jörgen Hildebrandt.

When Hazel and her mother arrive to the Operation Smile medical mission site at the University of Cebu Medical Center, there are more than 120 patients and families waiting for comprehensive health evaluations, which determine whether or not patients are healthy enough to receive surgery. Bhoniemae and Kristian are busy assisting the 56 families they brought from Bantayan Island and some smaller, nearby islands, answering all the questions they have. For many of them, this is the first time they’ve visited a big city.

“They come from rural areas, and many of them are afraid to come here – it is a big city, and they are not familiar with the surroundings,” Bhoniemae said. “They think they might be victims of scams and crime. Sometimes we must even convince them of our own goodwill. They have heard of illegal organ thefts and human trafficking, and are scared this could happen to their children.”

Operation Smile volunteer plastic surgeon Dr. Cherry Librojo of Manila explains the importance of local organisations such as Abounding in Love: “They are our eyes and ears on the ground. They know the culture and the sensitivities of the people, so they are more in tune with them. [Operation Smile medical volunteers] are strangers to them, even though I am Filipino myself. We come in and we perform our surgeries, but there is so much more to this. There are nuances that you need to know. They are the ones who are closing that gap. They’re very important. Because we may be the head, but they are our arms and legs.”

While Hazel is one of the 105 patients receiving surgery during the medical mission, another Abounding in Love child’s surgery is cancelled due to a high fever, making anaesthesia too dangerous to deliver. The child’s mother comes to Bhoniemae, crying as she seeks her advice. This is the second time the child has been denied surgery. The first time, the baby was too young.

“Please don’t give up hope,” Bhoniemae said, comforting the young mother. “Operation Smile is coming back in a few months and you will have another possibility at surgery.”

Downstairs in the operating room, Remedios can finally see Hazel after her surgery. Tears of gratitude and joy are running down her cheeks as she lifts her baby up in her arms.

“I am so thankful,” Remedios said. “Without you, my child would never have received this surgery.”

Photo: Jörgen Hildebrandt.

Closing The Gap: Surgical Training Rotations in Rwanda

Dr. Faustin Ntirenganya, the head of the surgery department at the University of Rwanda. Photo: Margherita Mirabella.

Dr. Faustin Ntirenganya isn’t one to mince his words when it comes to surgical care in his homeland of Rwanda.

“Don’t fish for us, teach us how to fish — I like that approach,” said Ntirenganya, head of the surgery department at the University of Rwanda. “I used to be involved in cleft surgeries and missions with people coming from abroad. The old way of doing business was to come, operate and go.

“Then I heard Operation Smile was looking at something more sustainable, which meant coming to train residents.”

Drawing on a history of medical missions and surgical programmes in Rwanda dating back to 2010, Operation Smile revitalised its relationship with the University of Rwanda to begin hosting new surgical training rotations in October 2015. The rotations aim to close the daunting gaps in the nation’s healthcare system related to cleft care and plastic surgery.

Photo: Margherita Mirabella.

Ntireganya is one of just two plastic surgeons serving Rwanda’s population of more than 11.9 million people. There are only 15 nurse anaesthetists and anaesthesiologists and 44 general surgeons. Most of these professionals are concentrated around Kigali, the capital city of this very densely populated nation. Though the most recent rotation concluded in March 2016, there is still much work to be done.

A volunteer surgeon with Operation Smile since 1998, Dr. Steve Naum of Grand Rapids, Mich. has been a central figure in the development of the rotations since his first visit to Rwanda in 2010. Naum volunteered at Rwinkwavu District Hospital, where he recognised the opportunity for Operation Smile to support surgical training there.

The effort started with small teams of volunteers in anaesthesia and nursing both at Rwinkwavu District Hospital and Butaro Hospital in Rwanda’s northern region before focusing on surgical training last year.

Ntirenganya and Naum share the same outlook regarding the importance of conducting the surgical training rotations.

Dr. Steve Naum, Operation Smile volunteer surgeon educator. Photo: Margherita Mirabella.

“It is easy for us to come to a place, do a number of cases, feel good about it and leave; but we don’t leave anything necessarily behind if we have not exchanged information or built some sort of knowledge or skill base for local surgeons to continue,” said Naum, who returns to Rwanda frequently to volunteer. “Ultimately, there is so much work and such a surgical burden in Africa that there is no way any volunteer service is going to get to all of it. The only way we are going to make a difference is to train people to continue doing that work.”

In addition to building surgical capacity for the future, Operation Smile volunteer plastic surgeon Dr. Bruce Ferris, who has been visiting Rwanda regularly since 2011, pointed to the benefit training rotations have on the safe surgical care patients receive.

“When I first started investigating doing rotations, it became very obvious to me that there were patients who needed surgical care that just weren’t getting it — languishing in hospitals for a very long time when they could have been cared for,” said Ferris, who practices in Wichita, Kan. “It made sense that if we could develop the rotations, many of these patients would be taken care of and not have to be hospitalised for the long term.”

Dr. Christophe Mpirimbanyi and Dr. Jean Paul Shumbusho review notes with Dr. Steve Naum. Photo: Margherita Mirabella.

The surgical residents involved in the 2015 rotation are a passionate crew, and among them is Dr. Christophe Mpirimbanyi, who was introduced to Operation Smile while working as a general practitioner and serving as an observer on a medical mission. Immediately, he was enthralled and inspired to become a plastic surgeon. Now in his third year of residency, his passion for positive surgical outcomes was almost palpable when he spoke of why this is more of a calling than a career.

“When you treat children with cleft lip and other craniofacial defects you don’t only treat them, but you also treat the community and even the family,” Mpirimbanyi said. “There are children that have been abandoned or stigmatised, but when you treat them, you give them hope.”

The success surgical training led to the inclusion of anaesthesiologists at the March 2016 mission at Rwinkwavu District Hospital.

Photo- Margherita Mirabella.

The training of anaesthesiologists in Rwanda is led by Dr. Paulin Banguti, who completed much of his medical training in the Democratic Republic of Congo before returning to Rwanda in 2004 with a desire to make an impact on the nation’s healthcare system. With only 15 active nurse anaesthetists and anaesthesiologists in the entire country, the workload is immense.

“If we can train 60 active anaesthesiologists by 2024, we’ll see if we can get to 100 or 120 anaesthesiologists by 2030 — then we will be closer to the goal,” Banguti said.

The path to success looks to be long and challenging, but ultimately the goal remains the same: a time when Rwanda produces enough doctors to meet their nation’s surgical needs. The residents’ enthusiasm following the 2015 training rotation embodies this hope for a healthier future.

“In October, we sent three of our third-year residents. They came back saying, ‘Why did we wait so long before starting something like this?’” Ntirenganya said. “They really benefited from this experience and the tremendous surgeons.”

Photo- Margherita Mirabella.

Striving Toward a New Tomorrow

Shennene holds her 1-year-old son, George, as they wait for his procedure during an Operation Smile medical mission in the Philippines. Photo courtesy of Aeson Baldevia.

A mother slips during pregnancy. A baby sucks his thumb in utero. 

Joemar and Shennene were told that’s what may have caused their 1-year-old son, George, to be born with a cleft condition – but they have many reasons to believe otherwise.

Sitting in the waiting room during Operation Smile’s 2018 medical mission in their hometown of Iloilo City, Philippines, Shennene and Joemar rattled off their family history.

Shennene was born with a cleft lip and palate and received care when she was young. And Joemar, with relatives who have cleft, understands the impact that the condition can have on a person and members of their family.

When Shennene was five months pregnant with their second child – a girl – an ultrasound suggested that their baby could be born with a cleft.

“Family must cause this,” Shennene said through a translator, with Joemar nodding in agreement.

Joemar said that they would’ve believed that these conditions are caused by slipping or sucking a thumb in the womb, but with such an overwhelming history of cleft in their families, there’s no other answer.

While there are still many misconceptions surrounding the cause of cleft, Operation Smile has teamed up with the University of Southern California (USC) and Children’s Hospital Los Angeles to conduct the International Family Study (IFS) in an attempt to better understand why the condition happens in the first place and, hopefully, find a way to ensure that no more people are born with cleft.

Trisha In, member of the four-person IFS team assigned to the medical mission in Iloilo City, said, “It’s really important for us to find out what we can do to prevent it because that’s one of the best ways to lower that burden in these countries.”

Operation Smile volunteer and IFS team member JR Lado speaks to the family member of a potential patient during the screening process of the medical mission in Iloilo City, Philippines. Photo courtesy of Aeson Baldevia.

For IFS team member JR Lado of the Philippines, nailing down the cause of cleft – and finding a solution – is a personal mission.

In 2009, JR received surgery for his cleft condition from Operation Smile and has been a dedicated volunteer ever since, working for medical records and then serving on the IFS team.

“I’m really looking forward to learning the real reason. I’m really looking forward to that day, if it happens, and I hope so,” said JR, who has collected samples on nine medical missions. “Me personally, I want to really know why or what the reasons are, or if there is any medication or any vaccination that will prevent it so that there will be no more children born with a cleft lip and cleft palate.”

The IFS team follows a series of steps to conduct their research during medical missions in a handful of countries – from Guatemala to Madagascar to the Philippines – where there are especially elevated numbers of people born with cleft conditions, Trisha said.

First, and very importantly, the team stresses to patients and their parents that participating in the IFS study is completely optional and has no bearing on whether their case is selected for surgery.

Once they receive consent from the patients and parents, each mother provides answers to a very thorough questionnaire; topics include their pregnancy, occupation, lifestyle, exposure to chemicals and more.

If the father is present, he’s also asked to answer a complementary questionnaire.

Next comes the genetic analysis. During screening day, the IFS team provides cotton swabs to every consenting patient and parent to collect saliva samples.

Almost 90 samples were collected during Operation Smile’s medical mission in Iloilo City – a drop in the figurative bucket of the number of samples that the IFS has amassed since its start in 2009.

As of 2019, the study has collected more than 16,000 individual saliva samples representing more than 7,000 families, creating the largest and most diverse genetic repository of cleft samples globally.

The team also receives samples from other patients around the hospital who were born without a cleft condition. This data serves as the control group.

“All of the data is sent back to the U.S., and we run that through the USC labs,” Trisha said. “We have people who look at the epidemiology behind it who take care of the data analysis, and they’ll look to see what trends exist to find out why oral clefts happen.”

Sifting through this research has revealed a potential connection between smoke inhalation from cooking over an open flame and a significant increase in cleft conditions.

In many of the low- and middle-income countries where Operation Smile conducts its medical missions, it’s common for families to prepare meals over open-flame cook stoves fuelled by burning wood or coal inside their homes.

This widespread cooking style typically lacks effective ventilation, creating an environment that could have detrimental effects on a pregnant mother and her developing baby.

IFS manager Freddy Brindopke collects samples from a young patient during Operation Smile's mission to Managua, Nicaragua. Photo: Margherita Mirabella.

“We all have different genetic predispositions, and that means different exposures can affect us based on our genes,” said IFS project manager Freddy Brindopke during a 2019 mission in the Philippines. “The same environmental exposure can affect two people differently over time because each person has a different genetic makeup.”

During Operation Smile’s 2018 medical mission to Iloilo City, George passed his comprehensive health evaluation and received surgery to repair his cleft condition.

George turned 1 year old just days after his surgery – an advanced birthday gift from Operation Smile his mother said. But to Shennene and Joemar, George has been their gift.

“The Lord gave George to us, and he is a blessing,” Joemar said.

Joemar and Shennene said that they feel happy that George received surgery for his cleft lip because he won’t be bullied when he grows up – he won’t have to endure the hardships that his mother experienced.

“Growing up was hard, but I don’t really keep the grudge inside me. I shrug it off,” said Shennene, who received surgery for her cleft palate 14 years ago. “If I keep it within me, I’ll just cry, so I don’t mind other people.”

Seated side by side with his wife, Joemar gently placed his hand on Shennene’s leg. And with affection shining in his brown eyes, he said, “I just love her so much. It’s been hard, but she’s managed it well. We’ll be happy after George’s surgery, and we think the sacrifices will be over.”

JR and Trisha hope that one day no child will be born with a cleft condition and that no parent will have to endure such sacrifice.

As the IFS continues in its search for both the answer and solution, it’s important for communities worldwide to fight the stigma surrounding cleft and accept these children as they are.

“Society needs to destigmatise cleft lip and cleft palate because a lot of people would just look at a child and automatically assume these things when our study has demonstrated that there is no clear-cut reason why this happens,” Trisha said.

“If it’s a lifestyle, if it’s environmental, if it’s genetics – that’s why we’re collecting more and more samples.”

Photo: Margherita Mirabella.

Future of Smiles: Durgapur Medical Mission

Patients and their families braved the unpredictable weather of monsoon season to travel to the Future of Smiles medical mission*, organized by The Inga Health Foundation in collaboration with Operation Smile and hosted by IQ City Narayana Multispecialty Hospital in Durgapur, West Bengal, India from Aug. 16 through Aug. 23, 2017. Photo: Valentina Marginean.
Patients and their families braved the unpredictable weather of monsoon season to travel to the Future of Smiles medical mission*, organized by The Inga Health Foundation in collaboration with Operation Smile and hosted by IQ City Narayana Multispecialty Hospital in Durgapur, West Bengal, India from Aug. 16 through Aug. 23, 2017. Photo: Valentina Marginean.
Eleven-month-old Ankan, pictured here with his father on screening day, received surgery for his cleft lip at the Future of Smiles medical mission. Reporting and photo: Mallory Lacy, Operation Smile U-Voice student volunteer.
Eleven-month-old Ankan, pictured here with his father on screening day, received surgery for his cleft lip at the Future of Smiles medical mission. Reporting and photo: Mallory Lacy, Operation Smile U-Voice student volunteer.

Operation Smile medical volunteers provided 193 comprehensive medical evaluations, which determine if a patient is healthy enough to safely receive surgery. Most of this mission’s patients, 140, were identified at pre-screening camps conducted by Operation Smile across the West Bengal region in the months leading up to the mission. A critical tool for recruiting patients, the camps are effective at determining the best candidates for surgery at upcoming medical missions while also allowing Operation Smile to earn the trust of those potential patients and their families. “Whatever we can do for these patients, we do it,” said Sumit Nandi, Operation Smile India’s patient coordinator who leads the camps alongside programme coordinator Bhaskar Mukherjee and a team of volunteers. “We will not desert them and we make sure they know that.”

A longtime patient of Operation Smile, 8-year-old Shuili returned to the Future of Smiles medical mission for her fourth (and final) surgery to repair her cleft palate. It wasn’t until four days after Shuili was born that her mother discovered her child’s cleft condition. Around the same time, she learned about Operation Smile. Shuili received her first surgery when she was 6 months old, but her case was very complex and has required several procedures throughout her life. Shuili’s mother works as a caretaker for a family whose son is a medical doctor in London. Since Shuili is unable to travel to receive speech therapy from Operation Smile, the kind doctor taught her speech exercises to practice. When she met our team, she said, “Hello, my name is Shuili” in perfect English. Her mother said that she is one of the brightest students in her third-grade class and when she grows up, she wants to be a medical doctor in London. Photo: Vini Mihill.
A longtime patient of Operation Smile, 8-year-old Shuili returned to the Future of Smiles medical mission for her fourth (and final) surgery to repair her cleft palate. It wasn’t until four days after Shuili was born that her mother discovered her child’s cleft condition. Around the same time, she learned about Operation Smile. Shuili received her first surgery when she was 6 months old, but her case was very complex and has required several procedures throughout her life. Shuili’s mother works as a caretaker for a family whose son is a medical doctor in London. Since Shuili is unable to travel to receive speech therapy from Operation Smile, the kind doctor taught her speech exercises to practice. When she met our team, she said, “Hello, my name is Shuili” in perfect English. Her mother said that she is one of the brightest students in her third-grade class and when she grows up, she wants to be a medical doctor in London. Photo: Vini Mihill.
Ganesh suffered from a cleft lip for 50 years before arriving at the Future of Smiles mission. There are no hospitals that provide surgical care in his community, but he learned about Operation Smile when patient recruiters came to his hometown with leaflets and posters promoting the mission. Ganesh jumped at the opportunity to finally receive surgery and travelled with his 27-year-old son to the mission site. Despite working as a street food vendor, Ganesh has always struggled to eat properly and stay nourished because of his cleft condition. He said that after surgery he looks forward to finally enjoying the food he makes and that he will look handsome for his wife. Photo: Vini Mihill.
Ganesh suffered from a cleft lip for 50 years before arriving at the Future of Smiles mission. There are no hospitals that provide surgical care in his community, but he learned about Operation Smile when patient recruiters came to his hometown with leaflets and posters promoting the mission. Ganesh jumped at the opportunity to finally receive surgery and travelled with his 27-year-old son to the mission site. Despite working as a street food vendor, Ganesh has always struggled to eat properly and stay nourished because of his cleft condition. He said that after surgery he looks forward to finally enjoying the food he makes and that he will look handsome for his wife. Photo: Vini Mihill.
In conjunction with the Future of Smiles medical mission, Operation Smile hosted an educational workshop for 57 nursing students and 12 nursing staff members of IQ City Narayana Multispecialty Hospital. Led by Linda Bucher, an Operation Smile volunteer nurse educator, the workshop kicked off with lectures introducing the organisation, its Global Standards of Care*, the various roles of nurses in the mission setting and cleft-specific nursing care. Then, the students and staff were divided into smaller groups, each of which followed a patient through every stage of the mission process as they received world-class care from the Operation Smile medical team. “This training deepens our relationship with the hospital and impacts the professional trajectory of these young students,” said Valentina Marginean, programme coordinator for Operation Smile. “It gave them exposure to what practicing nurses do every day – treating patients with dignity, care and compassion and allowing that empathy to be their drive to provide quality treatment.” Photo: Valentina Marginean.
In conjunction with the Future of Smiles medical mission, Operation Smile hosted an educational workshop for 57 nursing students and 12 nursing staff members of IQ City Narayana Multispecialty Hospital. Led by Linda Bucher, an Operation Smile volunteer nurse educator, the workshop kicked off with lectures introducing the organisation, its Global Standards of Care*, the various roles of nurses in the mission setting and cleft-specific nursing care. Then, the students and staff were divided into smaller groups, each of which followed a patient through every stage of the mission process as they received world-class care from the Operation Smile medical team. “This training deepens our relationship with the hospital and impacts the professional trajectory of these young students,” said Valentina Marginean, programme coordinator for Operation Smile. “It gave them exposure to what practicing nurses do every day – treating patients with dignity, care and compassion and allowing that empathy to be their drive to provide quality treatment.” Photo: Valentina Marginean.
Operation Smile volunteer nurse educator Linda Bucher, seventh from left, poses with participants of the Future of Smiles medical mission nursing education workshop. Photo: Valentina Marginean.
Operation Smile volunteer nurse educator Linda Bucher, seventh from left, poses with participants of the Future of Smiles medical mission nursing education workshop. Photo: Valentina Marginean.
Of all of the patients who received surgery during the Future of Smiles medical mission, Arju’s condition was unique. The 3-year-old was born with an extra finger on each hand and one extra toe. Some members of his family and community even considered the extra digits to be a symbol of good fortune, but his mother, Tarpasi, pictured here, wanted to be sure that the digits were removed before he started grade school. She worried that Arju would suffer from bullying due to his condition and that the digits – loosely attached by only skin – could be ripped off if he were to get into a scuffle with a classmate. Arju received surgery to remove his extra fingers and will return in two months for the procedure to remove his extra toe. Reporting and photo: Mallory Lacy, Operation Smile U-Voice student volunteer.
Of all of the patients who received surgery during the Future of Smiles medical mission, Arju’s condition was unique. The 3-year-old was born with an extra finger on each hand and one extra toe. Some members of his family and community even considered the extra digits to be a symbol of good fortune, but his mother, Tarpasi, pictured here, wanted to be sure that the digits were removed before he started grade school. She worried that Arju would suffer from bullying due to his condition and that the digits – loosely attached by only skin – could be ripped off if he were to get into a scuffle with a classmate. Arju received surgery to remove his extra fingers and will return in two months for the procedure to remove his extra toe. Reporting and photo: Mallory Lacy, Operation Smile U-Voice student volunteer.
When Rikta, a former patient of Operation Smile, learned about the Future of Smiles medical mission, she was inspired to make the two-hour journey from her home to Durgapur. “I rushed here to thank them,” said Rikta, who received her first cleft lip surgery at 6 years old from Operation Smile at a medical mission to Bolpur in 2005. Four years later, Operation Smile medical volunteers provided her with cleft palate surgery before she received a second cleft lip surgery from Operation Smile in 2014. It was after that third and final procedure that Rikta decided to “dedicate her life to helping humankind.” Now, the 18-year-old is an honours physiology student at Suri Vidyasagar College and aspires to become a nurse. “Without them, I could not be what I am now,” Rikta said of Operation Smile’s medical volunteers. Reporting: Mallory Lacy. Photo: Jack Schaeffer, Operation Smile U-Voice student volunteer.
When Rikta, a former patient of Operation Smile, learned about the Future of Smiles medical mission, she was inspired to make the two-hour journey from her home to Durgapur. “I rushed here to thank them,” said Rikta, who received her first cleft lip surgery at 6 years old from Operation Smile at a medical mission to Bolpur in 2005. Four years later, Operation Smile medical volunteers provided her with cleft palate surgery before she received a second cleft lip surgery from Operation Smile in 2014. It was after that third and final procedure that Rikta decided to “dedicate her life to helping humankind.” Now, the 18-year-old is an honours physiology student at Suri Vidyasagar College and aspires to become a nurse. “Without them, I could not be what I am now,” Rikta said of Operation Smile’s medical volunteers. Reporting: Mallory Lacy. Photo: Jack Schaeffer, Operation Smile U-Voice student volunteer.
Rikta waits with her mother during screening day at the 2005 Operation Smile medical mission to Bolpur, West Bengal, India. Operation Smile India Executive Director Abhishek Sengupta shared his memories of meeting Rikta when he was a student volunteer at that mission. He was the translator who helped Rikta and her mother communicate with the medical volunteers who provided the then 6-year-old with the first of the three surgeries she would receive from Operation Smile. “Rikta's journey is truly inspiring – it has been such a pleasure to see her grow up to this fine, ambitious, beautiful soul that she is today. It's a privilege. Thank you, Rikta!” Photo: Marc Ascher.
Operation Smile volunteer child life specialist Jennifer Fieten, left, explains her role on the Operation Smile medical team to an IQ City Narayana Multispecialty Hospital nurse, centre, and nursing student during the Future of Smile medical mission’s educational workshop. Child life specialists provide psychosocial care and educate patients and their families about the entire surgical experience, easing their fears and anxieties through therapeutic play and activities. Photo: Vini Mihill.
A 10-month-old patient dances as music plays from his mother’s phone shortly after receiving cleft lip surgery at the Future of Smiles medical mission. The Operation Smile medical team performed 140 surgeries over five days – well above the mission’s original projection of 120 surgeries. Photo: Vini Mihill.
A 10-month-old patient dances as music plays from his mother’s phone shortly after receiving cleft lip surgery at the Future of Smiles medical mission. The Operation Smile medical team performed 140 surgeries over five days – well above the mission’s original projection of 120 surgeries. Photo: Vini Mihill.

Scenes of Hope and Healing: Lima Medical Mission

Andrea holds her 2-month-old son, Kyungmin, as they both wait to receive their comprehensive health evaluations during screening day at Operation Smile Peru’s May 2019 medical mission in Lima. The international mission marked a major milestone for Operation Smile by recognising the 20th anniversary of when the organisation first began providing cleft surgery in the country. Photo: Margherita Mirabella.
Paediatrician Dr. Raquel Delgado of Peru performs a comprehensive health evaluation on a young patient to determine if they are healthy enough to receive safe surgery. Representing 16 countries from across Latin America and around the world, devoted and skilled volunteer medical professionals united together and provided screenings for 259 potential patients. Photo: Margherita Mirabella.
After a 30-hour journey, 38-year-old Andrea arrived at the medical mission with her husband, Santos, her younger brother, Juan Carlos, and her daughter, Liz. She had hoped that her son, Kyungmin, would receive a life-changing surgery, but medical volunteers informed her that he was too young.

Growing up, Andrea was the second eldest of nine children and lived in the small, remote area of La Libertad. There were no other families or homes nearby, so Andrea’s siblings were her only friends. This allowed her to avoid the harmful teasing and bullying that many children with cleft conditions can face. However, due to the isolation of her home, Andrea never attended school. Photo: Margherita Mirabella.
After a 30-hour journey, 38-year-old Andrea arrived at the medical mission with her husband, Santos, her younger brother, Juan Carlos, and her daughter, Liz. She had hoped that her son, Kyungmin, would receive a life-changing surgery, but medical volunteers informed her that he was too young. Growing up, Andrea was the second eldest of nine children and lived in the small, remote area of La Libertad. There were no other families or homes nearby, so Andrea’s siblings were her only friends. This allowed her to avoid the harmful teasing and bullying that many children with cleft conditions can face. However, due to the isolation of her home, Andrea never attended school. Photo: Margherita Mirabella.
This was Patrick at Operation Smile Peru’s May 2018 medical mission. After Patrick’s mother, Patricia, saw her baby’s cleft lip, she immediately began to investigate cleft surgery and organisations that could help heal her child. When she found Operation Smile Peru on Facebook, she called the office and made an appointment to meet with the medical team. It was there that Patricia’s hope grew for her son. Photo: Margherita Mirabella.
This was Patrick at Operation Smile Peru’s May 2018 medical mission. After Patrick’s mother, Patricia, saw her baby’s cleft lip, she immediately began to investigate cleft surgery and organisations that could help heal her child. When she found Operation Smile Peru on Facebook, she called the office and made an appointment to meet with the medical team. It was there that Patricia’s hope grew for her son. Photo: Margherita Mirabella.
Medical records volunteer Annika Brandin of Sweden stops for a moment to make a young patient smile during the busy and fast-paced environment of the mission. Photo: Margherita Mirabella.
Anaesthesiologist Dr. Mercedes Payan of Guatemala examines a young patient during one of the medical mission screening days. Throughout this part of the screening process, medical volunteers take and record patients’ blood pressure and other vitals to ensure that they are healthy enough to undergo safe surgery. Photo: Margherita Mirabella.
Ten-month-old Christopher with his mother, Heti, at the medical mission. Christopher’s father, Ezer, and Heti both have relatives with cleft, but they never imagined that it would be something that their own child would have to endure. But with the knowledge that surgery was possible and support from family and friends, Heti felt hopeful about Christopher’s future. After learning about Operation Smile Peru and the safe surgery that it provides patients at no cost, Heti and Christopher made the long journey from their home in the Santa Clotilde district of Loreto to the medial mission site in Lima. After receiving his comprehensive health evaluation, Christopher was deemed healthy enough for safe surgery from Operation Smile Peru. Photo: Margherita Mirabella.
Heti looks at Christopher’s new smile with wonder and joy after her son wakes up from his surgery. It was a beautiful moment that came after a lengthy journey. Even after travelling for nearly four days by sea in a decades-old military vessel, Heti and Christopher still had more distance ahead of them. It wasn’t until after a final place ride that the mother and son reached the mission site in Lima. But for Heti, every step they took and every obstacle they overcame was worth it. Photo: Margherita Mirabella.
Anaesthesiologist Dr. Gabriela Merino of Mexico, right, accompanied by anaesthesiology resident Dr. Mathew Lake of the U.S., gently carries Christopher into the operating room where he will receive surgery to repair his cleft lip. Christopher was one out of 112 patients who received life-saving surgery during Operation Smile Peru’s medical mission. Photo: Margherita Mirabella.
Drs. Victor Hugo of Bolivia and Giulia Amodeo of Italy help Andrea onto the operating table where she will receive surgery on her cleft lip. Before arriving to the mission, Andrea believed that Operation Smile only performed surgery on babies and young children. When she learned that the organisation also treated adults, Andrea felt very happy. After 38 years of living with a cleft lip, her chance at a new and beautiful smile had come. Photo: Margherita Mirabella.
Volunteer surgeon Dr. Edwar Alvarez of Ecuador, centre, transforms the smile of a patient during surgery. Photo: Margherita Mirabella.
Student team member Agustina Doria of Paraguay entertains a little boy before his surgery by blowing lots of bubbles with him and his mother. Photo: Margherita Mirabella.
Here are Patrick and Patricia one year later after the two travelled to Lima for Patrick’s post-operative consultation. On the morning of Patrick’s surgery, Patricia felt both nervous and excited to see how her son would look after surgery. Later that day, Patrick was back in his mother’s loving arms with a beautiful new smile. Once Patrick and Patricia arrived home after the 2018 mission, people in their community welcomed them back and began calling Patrick “el guapo,” which means “the handsome one.” By getting Patrick the care that he needed, Patricia was hopeful that she and her two children could begin a new life together. “I am very grateful to you all,” Patricia said to the Operation Smile Peru medical team. “Thank you for changing my life and my child’s life.” Photo: Margherita Mirabella.

Engineered for Healing: Operation Smile Colombia

Operation Smile Colombia co-founder Carlos Arturo Vargas. Photo: Jasmin Shah.

As the owner of a Colombian metallurgical engineering company, Carlos Arturo Vargas was once an unlikely candidate to become a co-founder of one of his country’s leading medical non-profit organisations.

Or was he?

In the years after his 15-month-old son died in a car accident, Carlos Arturo searched for meaning and purpose through the tragedy.

“It was tremendously terrible,” said Carlos Arturo, reflecting on the immeasurable loss. “Even though everyone said, ‘They’ll never understand why he was brought into this world,’ I made the decision that he had a mission and that we had to accept that.”

When Carlos Arturo’s cousin and business partner, Antonio Vargas, returned from a visit to the United States telling him about a family member’s involvement with Operation Smile, he knew that his son’s mission had finally been revealed – 15 years after his passing.

“We slowly forgot about it, until this new situation arrived providentially, and we embraced it,” Carlos Arturo said. “Not just me, but my whole family.”

Driven to honour his son’s memory, Carlos Arturo and Antonio decided to connect with Operation Smile and help the organisation extend international cleft surgery missions to Duitama, Colombia, in 1992*. After two successful missions that provided surgery to 200 patients, the cousins officially established the Operation Smile Colombia Foundation in 1994.

Dr. Mauricio Herrera, volunteer cleft surgeon and Operation Smile Colombia's medical director, left, performs surgery with the support of volunteer nurse Geraldin Ximena Rodriguez Tachak during the August 2019 local mission in Riohacha, Colombia. Photo: Rohanna Mertens.

Today, the foundation continues its pioneering work in providing Colombians affected by cleft conditions with access to safe surgery and multi-disciplinary support including psychosocial care, speech therapy, dentistry, paediatrics, otolaryngology (ear, nose and throat), genetics, nutrition and orthodontics. Patients and their families receive these services completely free of charge through two year-round care centres in Bogotá and Duitama and more than 28 local missions per year in many regions throughout the country, which often serve rural and remote communities.

Working into its 25th year as a domestic non-profit, Operation Smile Colombia has delivered more than 23,000 surgeries and over 250,000 patient consultations through its multi-disciplinary approach. The foundation’s commitment to treating the whole patient and supporting families through ongoing and comprehensive care has long served as a model of excellence for Operation Smile care centres and local missions around the world.

Volunteer dentist and orthodontist Dr. Nancy Rojas prepares to treat 7-year-old patient Juana at Operation Smile's care centre in Bogotá, Colombia. Photo: Jasmin Shah.

And the Vargas family remains woven into the fabric the organisation. Ernesto Vargas is the chairman of the foundation’s board of directors. Rodrigo Vargas Cabllero, Carlos Arturo’s son, established the foundation’s signature fundraising event “Por Una Sonrisa” as part of the annual Bogotá Half Marathon. Antonio’s son, Dr. Federico Vargas Mejía, grew up volunteering for Operation Smile Colombia and, today, is a volunteer cleft surgeon and board member. Esteban Vargas is a biomedical engineering volunteer-in-training and participates in the Por Una Sonrisa campaign. Carlos Arturo remains on the board in an honorary position.

Drawing on the resources of their company, Carlos Arturo and Antonio placed Operation Smile Colombia in a position of strength from the very beginning. At their headquarters in Duitama, the first international mission was hosted at a nearby hospital that was outfitted with state-of-the-art surgical equipment in accordance with the medical standards of Operation Smile and the approval of the Colombian Ministry of Health. By 1995, they had built a fully functional clinic on their company’s property that continues to deliver treatment as an Operation Smile care centre.

They also looked within their company to help launch the upstart initiative.

Operation Smile Colombia's executive director Martha Tristancho. Photo: Jasmin Shah.
Operation Smile Colombia's executive director Martha Tristancho. Photo: Jasmin Shah.

The husband of Operation Smile Colombia’s current executive director, Martha Tristancho, was an employee of the Vargas’ firm in 1992. A nurse by profession with experience working with the Ministry of Health, Martha was enlisted by Carlos Arturo and Antonio to volunteer her expertise to perform a census of patients living with untreated cleft lip and cleft palate in and around Duitama.

“In June, we began working in coordination with the government,” Martha said. “By August, we already had a census of more than 400 patients. By November, we hosted the first medical mission.”

Driven by a core group of Operation Smile Colombia’s current staff and volunteers who have been committed to its patients since these formative years, the foundation coalesced and opened the doors of its second care centre in Bogotá in 2002.

Operation Smile Colombia's care centre in Bogotá, Colombia. Photo: Rohanna Mertens.

“It was gratifying to see that patients didn’t just come in, receive surgery, then leave and that’s it,” said Stella Velandia, Operation Smile Colombia’s longtime head of pharmacy, who’s been on the foundation’s staff for the past 21 years and served as a volunteer since its founding. “After that, we follow up with their therapies … I’m proud to be able to participate in that.”

Stella began volunteering as an operating room nurse for Dr. Gilberto Mariño, who was a renowned Colombian craniofacial specialist, professor and Operation Smile Colombia’s lead volunteer surgeon.

Though Gilberto passed away nearly 20 years ago after battling brain cancer, his memory is honoured daily at the care centre in Bogotá that bears his name.

Operation Smile Colombia's head of pharmacy Stella Velandia. Photo: Jasmin Shah.

“He was a special person. He was absolutely a leader in what he did, but he did it differently – he did it his way,” said Dr. Mauricio Herrera, a former student of Gilberto, long-time Operation Smile volunteer surgeon and Operation Smile Colombia’s current medical director. “He really pushed us to study: On a Monday he would say, ‘OK, this is the book; you have to read this topic.’ That Wednesday, he arrived at the hospital with another book, saying, ‘Give me back my book, now you have to read this topic by Friday,’ and then he’d bring another book. So, I had to read three books per week, and I have a lot of work at the hospital.

“But it was amazing. That was his kind of strategy to push us to learn and to read at that time. It wasn’t available on the internet or in facilities like it is today.”

Mauricio said that being called upon by Gilberto to volunteer on medical missions was a special privilege only bestowed on a chosen few – his very best and brightest students. He added that it was Gilberto’s vision that laid the foundation for Operation Smile Colombia to thrive.

Operation Smile Colombia volunteer cleft surgeon and medical director Dr. Mauricio Herrera. Photo: Jasmin Shah.

“What I really remember about him was his commitment to complete patient care,” Mauricio said. “I think it was the pillar to build all of this, because all of the people who were training with him at the time are the older volunteers here today.”

Operation Smile Colombia pioneered the care centre and local mission models of care delivery within the Operation Smile organisation, which at the time was still firmly rooted in conducting large-scale international missions comprised mostly of medical volunteers from outside of the countries in which it worked.

But under the leadership of Gilberto and the Vargas family, the foundation tapped into the unified ethos of its volunteers: Colombian patients and families affected by cleft conditions deserve the very best ongoing and comprehensive care that they can offer.

Operation Smile Colombia volunteer cleft surgeon and board member Dr. Federico Vargas Mejía. Photo: Jasmin Shah.

“That is the most important thing here,” Federico said. “Because you can be in the surgery for 45 minutes or an hour, but the treatment lasts for 20 or 25 years. What the surgeons do is maybe 5 percent of the whole treatment. If we are working together with the speech therapy, with psychology, with the phonoaudiology – every specialty together – we can have better success with the kids.”

Operation Smile Colombia volunteer phonoaudiologist Olga Sarmiento works with a young patient at the Operation Smile Colombia care centre in Bogotá, Colombia. Photo: Jasmin Shah.

Martha added: “It’s definitely the need, the lack of opportunity to access healthcare at that time among the people here in Colombia. And I think what moves us is the desire to always do more, the desire to completely address the need.

“In fact, I think that is what keeps us going in this moment, because we have grown, step by step.”

Operation Smile Colombia volunteer psychologist Nubia Bercerra works with a young patient at the Operation Smile Colombia care centre in Bogotá, Colombia. Photo: Jasmin Shah.

*Editor’s note: Independent from the efforts of the Vargas family and Operation Smile Colombia, Operation Smile conducted an international medical mission in Colombia in 1988, the first in the country.

Completing the Smile: Q&A with Lucy Apeajei

Operation Smile Ghana programme coordinator Lucy Apeajei shares a smile with a young patient at the November 2017 medical mission in Koforidua, Ghana. Photo: Zute Lightfoot.

Times were tough for Operation Smile Ghana programme coordinator Lucy Apeajei when she was young.

By the time she was 10 years old, Lucy had to start working so she could help her single mother make ends meet. One day, she happened to walk by a woman conducting an empowerment campaign in her community for young girls like herself.

“I was fortunate to pass by when the person said, ‘Believe in yourself and go for anything you want to be,’” she said. The message had a deep and lasting impact on the young Lucy – so much so that she worked tirelessly to make it her life’s work to help fellow Ghanaians in need.

In 2010, she founded her own non-profit organisation, Just Care Foundation, “to empower women and children in rural communities to advocate for their economic, social and political rights.”

Through Just Care Foundation, she became involved with Operation Smile when she volunteered to lead an empowerment programme at the patient shelter of the April 2015 Cape Coast medical mission. Within the following year, she was hired to become the full-time programme coordinator of the newly-established Operation Smile Ghana Foundation.

We sat down with Lucy to learn more about her path in Ghanaian activism and how she’s helping Operation Smile to, in her words, “complete the smile.”

Operation Smile Ghana programme coordinator Lucy Apeajei at work during patient health screenings at the November 2017 medical mission in Koforidua, Ghana. Photo: Zute Lightfoot.

Q: How did you become involved with Operation Smile?

A: “I used to work with (Operation Smile regional manager for western and southern Africa) Sabrina Ghiddi’s husband, Simone, who knew about what I did with Just Care Foundation, because on my weekends I was always travelling and doing things for it. He told me Sabrina was volunteering for Operation Smile and asked if I could help. They briefed me on what Operation Smile does, and they asked me, ‘What do you think?’ And I said, ‘Well, after the final stitch, what else? After the stitch, what is life going to be like for that child? Does the child go home and continue to live on the street?’

“Of course, the surgeries are definitely life-changing, but having both the patients and the guardians at the mission is an opportunity to make a long-term impact on them – but how? So that’s where I knew I could help with Just Care Foundation – by running empowerment workshops to complete the smile.”

Q: Tell me more about the first mission on which you volunteered. It was the April 2015 mission in Cape Coast, correct?

A: “Yes! So on that particular mission, I teamed up with other organisations that came to teach the mamas. So I brought my empowerment programme to Operation Smile. During surgery days, we gave the patients and families at the shelter advice on livelihoods. So, for example, if you were a farmer, we taught you more farming skills that you could take back to your village and actually improve on your productivity and make extra money to send your child to school or to put your child in a trade. It went amazingly well and it was tremendous. And up to now, we have patients and mamas who are using these skills. Some are beading on slippers, and this is their work today. To me, that is also a lifetime transformation. To me, that is a complete smile.”

Operation Smile Ghana programme coordinator Lucy Apeajei works with British anaesthesiologist Dr. Clive Duke during the November 2017 medical mission in Koforidua, Ghana. Photo: Zute Lightfoot.

Q: Are you still involved with Just Care Foundation, and what was your inspiration to start it?

A: “I am still the CEO, but I’m now more remotely involved. I have an amazing team of volunteers in place that run its programmes. Because I am the founder, I know that nothing can detach me away from it completely, but I don’t run day-to-day affairs because I trust my team and they are doing amazingly well.

“I believe there is a girl out there somewhere who only needs a lesson. After she hears a message of empowerment, her life will be transformed as mine was. So at Just Care Foundation, we empower adolescent girls from the streets and the rural areas to break the cycle of inter-generational poverty. I believe that if you lift up one girl and empower that lady to do something for herself that she can pull her entire family out of poverty. Until that happens, the cycle of poverty continues. And this work can be done by just one girl. So I started with one girl; now I’ve had five girls become nurses and, to me, it’s amazing.”

Q: How did you become the full-time programme coordinator for Operation Smile Ghana and what does it take to do the job?

A: “So in early 2016, Sabrina told me that Operation Smile Ghana needed a programme coordinator, and after seeing how I organised my workshop and how everything went very smoothly with the hundreds of people at the patient shelter, they thought I would be the best person for the job. My first mission was in Ho in March 2016, and it was marvellous. We still make sure that educational and empowerment programmes are incorporated at the patient shelters, and Clement (Ofosuhemeng, Operation Smile Ghana’s patient coordinator) does a wonderful job of coordinating that. I was programme coordinator for three missions with support from Kelvin Turner (Operation Smile international programme officer), and my first mission as lead programme coordinator was here (at Eastern Regional Hospital) in Koforidua in November 2017 and I just did our first local mission (also in Koforidua in January 2018)…

“As lead programme coordinator, you don’t just lead the volunteers. I have to make sure that everything about the mission works and that all of the logistics it takes to run it come together. So before our mission, I go onsite and look for a patient shelter location and a hospital. Then, after that, I make sure that the patients will have everything they need at the shelter. Then, when it’s time for the mission, I make sure the volunteers are all taken care of, that the hospital is ready for them and that things run smoothly overall.”

Operation Smile Ghana programme coordinator Lucy Apeajei leads patients and their families through the post-operative ward at Eastern Regional Hospital during the November 2017 medical mission in Koforidua, Ghana. Photo: Zute Lightfoot.

Q: What are you most proud of having conducted Operation Smile Ghana’s first local mission?

A: “I’m so proud of this team – Sabrina, Clement, the three of us – coordinating everything together to make it very successful. I’m proud of our volunteers, the local volunteers, for stepping onto this stage and making the mission safe and successful… I’m proud that the hospital was good and that everything went perfectly if you look at the pieces all together. All of the patients were safe; we didn’t have any serious incidents nor any serious emergency, so I’m also proud of that. Also, through our training and education programmes, we have empowered our volunteers to reach higher standards so they are better able to provide to any patient they encounter, so that is also a great achievement.”

Q: Anything else you’d like to add?

A: “I want to say a big thank you to my colleagues Sabrina and Clement for all of the support that they have given to make this mission possible, and all of the people who sponsor us both locally and internationally. Most importantly, thanks to the volunteers for the passion and commitment that they give to all of Operation Smile’s programmes, and to the international programme coordinators like Kelvin Turner – thank you so much Kelvin for all of your help… And it wouldn’t have ever happened without the Co-Founders of Operation Smile, so we say thank you to Dr. Bill and Kathy Magee. We thank everyone that makes our programmes in Ghana possible! And lastly, to the medical professionals of Ghana, I entreat you to help us change lives while improving your skills by volunteering with Operation Smile Ghana!”

The staff of Operation Smile Ghana: programme coordinator Lucy Apeajei, left, patient coordinator Clement Ofosuhemeng and regional manager Sabrina Ghiddi. Photo: Zute Lightfoot.

The Extra Mile

Sabrina Ghiddi, Operation Smile's regional manager of western and southern Africa, shares a laugh with a patient's mother and Clement Ofosuhemeng, Operation Smile Ghana's patient coordinator, during the November 2017 medical mission to Koforidua, Ghana. Photo: Zute Lightfoot.

Before Sabrina Ghiddi became involved with Operation Smile’s work in Ghana as a non-medical volunteer in 2013, she didn’t know that the organisation existed.

However, the Italian transplant did know that she wanted to dedicate her life to helping those in need.

“When I came to Ghana, I was looking for volunteer opportunities and a lady from a malaria (non-governmental organisation) connected me with Operation Smile so that I could attend a medical mission,” Sabrina said. “I was very excited, despite not knowing exactly how I could contribute.

“All of it was very much by chance.”

Happenstance may have led Sabrina to Operation Smile, but her passion ensured that she would forge a path from starting out as an assistant to child life specialists on medical missions to becoming a full-time employee of Operation Smile as its regional manager of western and southern Africa.

Under her leadership, Operation Smile’s work in Ghana transformed from being on the brink of ending to becoming firmly established when she registered Operation Smile Ghana as a domestic non-profit organisation in 2015. Since then, the foundation has experienced incredible growth and success that’s been fuelled by her relentless commitment to Ghanaian patients and families affected by cleft.

Sabrina Ghiddi, Operation Smile's regional manager of western and southern Africa, talks to patients' mothers during a 2015 medical mission to Ho, Ghana. Photo: Margherita Mirabella.

The April 2015 medical mission to Cape Coast proved to be the turning point.

In the months leading up to what would be her final mission as a volunteer, Sabrina learned of the possibility that Operation Smile was considering suspending its work in Ghana due to low patient turnouts. However, Sabrina knew those numbers didn’t reflect the need for cleft surgery in the country. She knew that the patients and families were out there, mostly scattered around Ghana’s multitude of rural villages, but they weren’t being reached nor empowered to seek Operation Smile’s care.

Inspired to do more to help, she, along with then-volunteer Clement Ofosuhemeng, mounted aggressive cleft awareness and patient recruitment campaigns ahead of the Cape Coast mission. The message of hope and healing resulted in a turnout of more than 400 potential patients, proving that the patients were, indeed, out there.

Sabrina Ghiddi, Operation Smile's regional manager of western and southern Africa, dances with a young patient at the patient shelter of the January 2018 local medical mission to Koforidua, Ghana. Photo: Zute Lightfoot.

“I think that before you move on from a place, you need to be very, very sure that there aren’t patients who need you.” Sabrina said. “I knew that this was something that I could contribute to. So I engaged Simone, my husband, who was able to get a $500 sponsorship from his company for us to go out and find these patients.”

In their free time, Sabrina and Simone rode their motorcycle throughout Ghana’s far-flung communities in search of patients and families affected by cleft – no easy task as most of the rural roads there are pocked with dangerous potholes.

“Creating awareness, engaging community members to champion our message and finding people in need was very fulfilling. On the other end, we had a huge responsibility – missing a village or a hospital could have kept someone from learning about Operation Smile and the surgical care we provide,” Sabrina said. “We tried to go everywhere we could, engaging as many people as possible. In particular, we approached the pastors of Christian churches and imams of Muslim mosques, who would then disseminate information about Operation Smile to their followers.

“Because of the stigma of cleft here, we knew that the pastor, who is someone that people really believe and trust, would be the best person to transfer the message to try to remove the superstition.”

Sabrina Ghiddi, Operation Smile's regional manager of western and southern Africa, and Clement Ofosuhemeng, Operation Smile Ghana's patient coordinator, work late hours with the mother of a patient during the January 2018 local medical mission to Koforidua, Ghana. Photo: Zute Lightfoot.
Sabrina Ghiddi, Operation Smile's regional manager of western and southern Africa, and Clement Ofosuhemeng, Operation Smile Ghana's patient coordinator, work late hours with the mother of a patient during the January 2018 local medical mission to Koforidua, Ghana. Photo: Zute Lightfoot.

Though their patient recruitment effort was a resounding success, the Cape Coast mission was only equipped to provide 75 surgeries – the amount of equipment, supplies and volunteers available were based on the patient turnouts of the previous two missions. The team stretched its resources to deliver 90 surgeries.

“It was heartbreaking for me and the team to witness hundreds of families with babies and kids with cleft be turned away,” Sabrina said. “That moment changed the course and direction of Operation Smile Ghana, but also the direction of my life, my values and, I believe, the purpose of my life.”

Suddenly, it became clear that the need for cleft surgery in Ghana was massive. Operation Smile then strengthened its investment in the country, hiring Sabrina to be regional manager and began conducting two large-scale international medical missions per year. Later in 2015, she officially incorporated Operation Smile Ghana and hired Clement as the foundation’s patient coordinator and Lucy Apeajei, another Cape Coast volunteer, as its programme coordinator.

“Who would’ve ever thought that three volunteers on that mission would become the Operation Smile Ghana team within the year,” Sabrina said. “We are very different from each other, but we are driven by the same passion and joy in going the extra mile to serve others. I believe that whatever you are passionate about, you will succeed as long as you are willing to work hard enough to do it. I think this is the key of our success.”

Sabrina Ghiddi, Operation Smile's regional manager of western and southern Africa, plays with a young patient during a 2015 medical mission to Lilongwe, Malawi. Photo: Margherita Mirabella.

With volunteer cleft surgeon Dr. Opoku Ampomah, the head of Ghana’s National Reconstructive Plastic Surgery and Burn Centre, serving as medical director, Operation Smile Ghana began attracting medical professionals from across the country to serve as volunteers and benefit from the training and education opportunities offered at the missions.

Since then, Sabrina has been steadily raising the organisation’s profile among Ghana’s business community, securing critical corporate partnerships that have fostered the exponential growth of the foundation.

In little more than two years of existence, Operation Smile Ghana notched a major milestone when it hosted its first local mission comprised almost entirely of Ghanaian volunteers at Eastern Regional Hospital in Koforidua in January 2018.

“It is truly wonderful, what we’ve been able to achieve,” Sabrina said. “This could have never been possible without my team, the dedicated volunteers, the compassion and support from our sponsors, local stakeholders and board of directors.

“We have achieved a lot so far but there is still more to be done – we will not stop until we heal every child with a cleft in Ghana. We know that the responsibility that we have in the country is remarkable, but the fulfillment of our work is priceless.”

Sabrina Ghiddi, Operation Smile's regional manager of western and southern Africa, talks to a young patient and her mother during the November 2017 medical mission to Koforidua, Ghana. Photo: Zute Lightfoot.