Denis Gill, MB BSc DCH FRCPI FRCPCH
Operation Smile is one of those medical charities that amply demonstrates the power of military organization and the ability of skilled surgeons, especially orthopaedic, plastic, and ophthalmological surgeons, to parachute into foreign places and change lives forever. We physicians care for and treat people: surgeons can cure them.
I have had the opportunity and pleasure to travel on three Operation Smile missions to Morocco, Kenya, and Ethiopia. Operation Smile's primary goal is to repair cleft lips and palates. Founded in 1982 by Bill Magee, an Irish-American plastic surgeon, it attracts volunteers from eighty countries, operates annually in sixty countries, and has provided more than 220,000 free plastic procedures.
Here follows a short account of my three missions, each of which were amazing, memorable, rewarding, and remarkably well organized.
FIXING CLEFTS IN THE RIFT VALLEY
OS = Latin for mouth
OS = Operation Smile
OS = Outstanding service
My trip to the Rift Valley with Operation Smile (O.S.) all started with Michael Earley's persuasions, a tortuous credentialing process, an Advanced Pediatric Life Support (APLS), and a request from my friend Teri for a paediatrician to travel to Kenya. About a year later, I, an OAP "paddy-atrician," was initiated into the O.S. Club.
First sightings of other O.S. volunteers were made at Amsterdam Airport as the U.S. group headed to Africa. Thence we came to Nairobi, where the group amalgamated with other, T-shirted, transatlantic, and tired—but enthusiastic—volunteers.
And so to screening. Out in the tented garden we saw a sea of expectant dark faces most phlegmatic, patient, and uncomplaining. The children were stoic, passive, inquisitive and mainly mute. We met individuals named Godeon, Regina, Faith, Mercy, Mary, Joseph, and Denis. Everyone was moved by the big quiet father of three lovely girls—Sienoi, aged 10; Seema, 3 years; and Senjura, one and three quarter years—who travelled from Masai Mara to have their primary cleft lips fixed. And so it came to pass skilfully and successfully all smilingly reflected in their unfamiliar mirrors the next day.
- What caused the cleft? "God's Will"? "God's Plan"?
- Even the poorest seemed to have a mobile phone
- Breast feeding al fresco in gardens, corridors, wherever.
- Industrious washing each morning of everything. Cleanliness is definitely next to godliness!
- 36-year-old with unrepaired primary cleft lip.
- Unfortunate girl with enormous mushrooming keloids dangling like navel oranges from each ear lobe.
- Goggle-eyed, gobsmacked, wondrous children reduced to relaxed contentment by Allison the life / play hypnotizer.
Operation Smile epitomises the power of surgery and anaesthesia. Parachute a bunch of skilled people into a place, almost any place, and let them fix, cure, remove, repair, incise, excise things. Surround these cutting edge specialists with a support team of dentists, doctors, nurses, paramedics, all professional and altruistic, and the winners
are the patients, the poor, and those lucky enough to make it through the screening process. A huge logistical and organizational exercise of magnificent beneficence.
THE OSMIK TEAM
OSMIK = Operation Smile in Kenya.
Nakuru is Operation Smile's longest serving site and now an example of local collaboration and international cooperation. Organised by la bella Joella and delightful Diana, the mission went smoothly, swingingly, satisfying and surprisingly quietly and quickly. No fights, fracas, or face-offs. Only one broken down bus. And perhaps a touch of friction over theatre lists.
The whole exercise was an example of experienced but unrehearsed cooperation between a bunch of Westerners and Africans to achieve a desired, admirable, and extremely worthwhile end. The outcome was changed faces, improved self esteem, wry smiles, and delighted inner dignity.
- Did we cut it in Kenya? We sure did.
- Did we experience Kenyan hospitality and expertise? Most certainly.
- Did we admire the gorgeous geography of the Rift Valley? Who could not.
- Do we now know the difference between a dermoid, keloid, fibroid, lipoid, epitheliod, and a droid? Of course.
POUR L'AMOUR D'AZZEMOUR
It is always good to get out of Ireland's greyness and coldness of January. And so to Azzemour, a small Moroccan city about 100 km south of Casablanca on the Atlantic shore. There the O.S. team gathered in chalets by the sea, met by an Atlantic roar, a welcoming dinner with Moroccan music and dancing, and a selection of Moroccan treats. A mostly Moroccan team with some French, two Jordanians, two Italians, and one Irish. Naturally French and Arabic become the lingua franca of the group, led by big Abdou and lovely Fouzia.
As is usual on O.S. missions, day one is the screening session. Hundreds of hopefuls turn up at the hospital gates in the dark, cold morning in layers of clothing and monkish robes for the men. The children, generally healthy, well behaved, and stoic, are presented with their clefts, their revision requirements, their scars, and above all their hope of inclusion. About 160 patients, including twenty to thirty adults were screened and sorted. We returned home late in the dark to a sound slumber hastened by the background rumble of the Atlantic surf.
Day 2, 3, 4, and 5 then follow an organized fashion. Up early, too early! Dejeuner in a tent outside of the hospital consists of delicious pancakes, baguettes, croissants. And thence to battle. Pre-op assessments, operative lists, shared assignments, an exercise in organized chaos, a clamour of crying hungry children, a collection of mostly mute mothers. A long hard day for the surgeons from early AM to late PM.
Lunch on the trot, lovely Moroccan "hamburgers," teamwork, processing, good surgery, competent anaesthetists. Few problems. A wheeze here. A small bleed there. A touch of stridor. A little temperature. And so the days, though long, glide past. One day of selection and four days of operations and fixing.
Morocco seems still to have a strong French influence. On language. On bread. On cars. On life. On a people surprisingly secular.
Unexpected and unannounced "goodies" would suddenly appear—nuts, almonds, pastries, and delicious delicacies. The provincial governor brought a retinue of obeisant sycophants and a selection of "sweeties," the sponsors' smiles and savouries.
All went well over four days of industrious, devoted, and skilled surgery. Only one complication occurred, a palatal bleed requiring redoing and re-sewing. Good organisation, good communication, and extraordinary generosity of skills and time meant that over 100 people had a problem solved, cured, revised, repaired, or ameliorated.
Prodigious photographic documentation supported the surgeons. Saturday was a chance to view and review the good work done. And the people and group departed on their various ways. Friday night was for dining, dancing, even drinking. A small bar was located locally and our alcohol free week concluded.
ETHIOPIA OP SMILIA
The anaesthiologists called it "Etheropia," the surgeons named it "Operopia," the physicians thought of it as "Offer Hopia," and the others considered it "Ethi-op-Hopia." So in October 2012 (Amharic 2005 or so), an Operation Smile mission descended upon Mekele, Tigray Province, in Northern Ethiopia.
The fifty or so members of this team travelled one to four days from Alaska, California, Canada, Sweden, Russia, Australia, Ireland, Italy, the UK, and Egypt to participate in this mission. Most of its members were from the U.S., including the organizers, managers, directors, and coordinators Melissa, Kia, and Sara. We called Kirsten, Susan, Barbara, Maria the "Swedish Sisters"; Ruth, Eoin, Triona, Cora, and Denis were the "Paddy party"; Giorgio was the sole Italian; and Eric from the UK completed the European Union contingent.
Some, such as Andy and Labib, were on their twentieth mission. Others like Amy, Mike, and Deirdre were on their very first. All were there because they wanted to be. All had volunteered their time, travel, experience, energy, skills, commitment, and, above all, care to be there. This was but one of some seventy missions that Operation Smile organizes and carries out each year with military precision and coordination. The organisation could be called Operation Cooperation for the manner in which it gels total strangers into a functioning unit.
The call came in August from Mairead, Operation Smile's coordinator. Would I go to Ethiopia in October? I immediately started asking questions. Where is Mekele? What is the weather like? Will we need oxygen? What vaccines? What about malaria? Surely there's no rabies? Will it be cold at night?
Sara, the OSI program coordinator, snowed us under with information, checklists, advice, travel hints, and forms galore. Is Denis Gill who he says he is? Credentialled? APLS certified? A registered practitioner? A bone fide paediatrician?
A seasoned Ethiopia traveller warned of fleas. My ex-neighbour, Fiona, an expert on Ethiopia because of her work on stoves for Ethiopia, proved positive and perspicacious.
Mairead ticked the boxes, scanned the documents, and gave me the go-ahead.
Tourism and travel are definitely over. Up at 0530, team talk at 0600, bus at 0630, arrive hospital at 0645. A modern hospital, just five years old, that's big (500 beds) and filled with hopeful people await our arrival.
The Operation Smile machine swings into action smartly and efficiently. Nurses' vital signs station are set up, paediatricians and anaesthetists gather together, as do surgeons, speech therapists, dentists. The process starts with and ends with clinical records and patient photography.
To the outside it might have appeared like organised chaos but after a long day, 153 supplicants were assessed, screened, categorized, notated, numbered, filed, and filmed for the critical categorizers, the surgeons. Those rated 1 or 2 will get surgery, those rated 3 might and, those rated 4 or 5 are unlikely. A long hard days work turns into night. We left in the dark and returned to Hill Top at 1930, well after nightfall.
The highlight of my first day was a tall, dignified, grey haired man with his face swathed in a scarf. On exposure, he had an unrepaired bilateral cleft lip, a large gap, and exposed teeth. He also had a wide cleft palate. He explained that he had not known it could be repaired and travelled with his daughter. We hoped and prayed it could be done.
The second screening day was much quieter with a small queue outside the door. We felt less hassle and had more time. I notice that several children had had uvulectomies. Who did it? The local healer. Many boys were circumcised. Who performed it? The cutting man–and surprisingly expertly to boot.
Giorgio, from Italy, noted that this was il calma prima la tempesta (the calm before the storm).
This is what it is all about. Surgeons using their skills, standing on their feet for long, hard days, securing separated clefts of lips and palates. The surgeons are an experienced bunch: two from the U.S, one Canadian, one Scot, one Iraqi, one Egyptian, and one Irishman. The operating room (theatre) is a place of quiet focussed intensity and industry. The surgeons are the quintessential cogs in a highly oiled, well organised, and functional O.S. wheel, supported and succoured by their operating room nurses and anaesthetic colleagues.
Pre-operation (pre-op) leads to operation leads to recovery leads to post-operation (post-op). We see steady stream of twenty-five patients each day and fifteen on the last half day. As we assess, cut, care, and carry, we encounter very little crying. Children were comforted by their mothers and a few fathers. Some of the adults appeared oppressed and depressed by overwhelming poverty. The pre-op room seemed sometimes to be suffused by a speechless sullen silence.
O.S. works because people choose to do it. Because they are needed. Because the work is rewarding. Because of the engendered team spirit. It seems to me partly altruistic, partly touristic, partly good practice, partly Christian, but mostly a chance to care for children, to value cleft correction, and to give back some of the good and generosity that life has given us.
The surgery days are truly long and hard, lasting twelve to fifteen hours for all concerned. But the O.S. people are glad to give of themselves, their skills, their time. The standard days saw children operated on in the morning and adults in the afternoon.
Of memories there are many
- Of the wonderful trip to the rock-hewn church of Abreha we Atsbeha. Of the luck of chancing upon the preparations for an important pilgrimage.
- Of the fifty-year-old man's astonishment and admiration of his miraculously repaired upper lip. And his awe of the surgeons.
- Smiles from sutured lips from satisfied parents and all for our clicking cameras.
- The power of surgery and it's support team to parachute into a place, fix faces, clefts, scars, malformations and then depart leaving transformed appearances and lives.
- A hyena call waking us up one morning.
Just a bunch of good people.
Working together. For a good cause.
Full stop. A Mekele Mission.
A Mission of merging skills and mending splits.
denis gill, MB BSc DCH FRCPI FRCPCH, is Retired Professor of Paediatrics RCSI Dublin. He is also former paediatric nephrologist CUH Dublin, the author of Paediatric Clinical Examination (5th Ed, 2007), former President British Society for the History of Paediatrics and Child Health 2012-2015, and a volunteer for Operation Smile.