Making children smile

When Mary and Martha Meas were born in Cambodia more than two years ago, their birth was greeted with joy-and sadness. Mary Meas had a bi-lateral cleft lip, which left her face looking as though a small trunk was growing out of her nose. Her family inquired about surgery in Singapore, Hong Kong, and the Philippines, but it was too expensive.

Providentially for Mary, her father is a Cambodian pastor, and news of her plight passed from an American missionary's family to Patrick Beckham of Austin, Texas. Dr. Beckham was the right person to ask. For years he has been doing free surgery on his own and with Austin Smiles, the charity founded by the Austin Plastic Surgery Society. Since 1987 his group has performed more than 2,500 free surgeries outside the United States, primarily in Central and South America, and about 1,000 free surgeries in the 10-county region around Austin.

Operating on Mary Meas had special appeal to Dr. Beckham. As a Christian he looks for ways to combine his faith and his interest in missions with his medical work. Operating on a pastor's daughter-especially a pastor who as a boy had escaped from Pol Pot's killing fields, fled to Thailand where he came in contact with missionaries and was converted-is the kind of work he likes to do.

The doctor looks like a cross between former president George Bush and a mustachioed Pat Robertson. He smiles when he tells how his church, Covenant Presbyterian, helped find a place for Mary and her father to stay once she was out of the hospital. He brings out before and after pictures, which show a beautiful little girl whose face-and future-were transformed by a relatively simple operation.

That's the philosophy behind Austin Smiles. From the very beginning, the doctors decided to focus on cleft lip and palates "because it is such a high impact operation.... With a relatively simple, reasonably quick one or two operations, you can absolutely change a child's life totally," says Dr. Jim Fox, one of the founders.

Since 1990 the group has traveled most frequently to El Salvador, a land torn by years of civil war. In that country about the size of Massachusetts, 14 plastic surgeons struggle to meet the needs of six million people. Local doctors, paid about $500 a month by the government, have neither time nor finances to provide charity care for all the poor people who require lip and palate surgery. That's where groups like Austin Smiles come in.

A trip to El Salvador usually includes 40 volunteers, all of whom pay a large part of their own way. The doctors pay all their own expenses-airfare, hotel-while other volunteers pay a $500 sponsorship fee, which basically covers the cost of airfare and food. Austin Smiles pays for their hotel and transportation costs not covered by the $500. Despite the cost, Austin Smiles has had over 500 volunteers go on trips since 1988.

In addition to their out-of-pocket expenses, those who volunteer often have to take vacation or administrative leave without pay. The doctors give up the income their practices could generate in the week they are away-which can be as much as $20,000. Dr. Jim Cullington, another one of Austin Smiles' founders, says, "We're talking the best of what medicine's about. Doing it just because it's the right thing to do."

Preparations for each of the three-times-a-year trips begin two years out when Executive Director Kendyl Richards, the organization's only full-time paid staffer, and Medical Missions Director Carolyn Hardwick set the dates for the trip. At that time they begin the process of putting together the team that will go on the trip. Each trip requires four to five plastic surgeons, six to seven anesthetists, four operating room nurses, four surgical techs, three recovery room nurses, and one nurse and one family practice physician to do triage. Recently, Ms. Harwick has added Ear Nose and Throat doctors to the list. The rest of the team is made up of translators and general volunteers who hold babies, comfort families, wash and sterilize equipment, change beds, and act as general go-fers.

Ms. Hardwick also puts together the supplies required for each mission. She buys or finds donated drugs and collects open but unused medical supplies from Austin's Children's Hospital where she works part-time-in order to have time for Austin Smiles-as an emergency room nurse. (Opened but unused gloves, masks, gowns, drapes, suction tubes, sutures, etc. cost too much to reprocess for use in America, but are still usable by the doctors in El Salvador.) About 70 percent of the supplies for each mission are donated; in kind donations-medicines, professional fees, medical supplies-total about $1 million each year.

The gathered supplies for each trip are packed a month ahead of time into 26 boxes and 18 purple-and-turquoise crates. Everything the team will need in El Salvador, except for operating tables and anesthesia machines, is shipped from Austin. It's the equivalent of packing to move a large home three times a year.

In El Salvador, Austin Smiles works with La Familia (the El Salvadoran equivalent of Health and Human Services) and the military. La Familia makes sure that the 44 crates and boxes are cleared through customs and received at the military hospital in San Salvador where the surgeries take place. By the time the Austin Smiles team arrives, the military and La Familia will have publicized the visit through ads placed in newspapers and on TV and radio. The military through its bases gets the word out even in isolated villages.

The group leaves Austin on a Saturday and returns the next Friday. The doctors operate from Monday through Thursday, doing as many as 20 operations per day.

Early Monday morning potential patients are sorted by problems: cleft lips here, palates there, burns and other problems here. Though the parents wait patiently, the line is noisy. Some of the hundreds of babies scream. Doctors and translators go down the line, evaluating each patient for surgery. Some are too young. Cleft lips can be done at three months, but palates need to wait until about three years. Some are too sick. The young and the sick are sent home with the promise that "we will be back." That's one of the reasons that Austin Smiles operates primarily in El Salvador. Doctors know if they can't operate during one visit, they will be back in four months for the next.

While the plastic surgeon is evaluating patients on one level, a family practice doctor is making another kind of evaluation: Is the patient healthy enough to undergo surgery? Carolyn Hardwick says it is difficult to get good medical histories from many of these patients, but a family practice doctor is able to detect children who may not make it through safely because they have asthma, infections, or dehydration.

Once the first four patients are chosen, the action moves upstairs where three operating rooms are ready. One of the rooms has two tables in it, so four surgeries are often taking place at the same time. The rooms have been fitted with the supplies brought from Austin. Cameramen from the military are everywhere, poking their cameras from above and below, trying to capture every surgery and every emotional moment for posterity and public relations. Austin Smiles has brought a great deal of positive press to an unpopular military. For the most part, the volunteers are able to ignore the cameramen, maneuvering around them like mere pieces of furniture.

Surgeries take place one after the other, with just enough time in between to prepare the table for another patient and sterilize the equipment. It is a scene of constant motion, interrupted frequently by emotional moments. Mothers have to hand their children to strangers who, in many cases, speak a foreign language. Carolyn Hardwick says, "It's a terribly frightening thing for these parents to do. I don't know if I could just hand someone my child." And yet they do.

The babies stare with big-eyed wonder at the strange foreign-speaking adults who hold them, and the machines, lights and cameras that clutter the operating rooms. They scream and struggle when the anesthesiologist places the plastic mouthpiece over their noses and mouths. Administering anesthesia to these young patients, who often have airway problems related to their deformity, is not easy.

Dr. Wayne Porter, chief of anesthesiology at Children's Hospital in Austin, says that cleft lip and palate surgery poses special problems for an anesthesiologist. Not only are the children young-in the case of cleft lip they may be just three months old-but the anesthesiologist is dealing with the babies' airways. "You're in the middle of their airway, in the back of their throat. You're operating on it. You've got bleeding and swelling, and the airways are not all that normal to start with," he said. The challenge is even greater in El Salvador. While the military hospital is new and modern, it lacks the standard back-up equipment found in good U.S. hospitals. He says, "Everything has to go perfectly in a less than optimal circumstance.... There is very little margin for anything going wrong." Experience is essential: "If I've done tons and tons of children, but I haven't done El Salvadorian lips and palates with their anesthesia, then I'm a novice."

The doctors who go on these trips seem particularly struck by the appreciation the parents express. Their gratitude, Dr. Porter says, is in contrast to the attitude of many patients in the United States: "We expect everything to be perfect, and if it isn't, somebody has to pay. Whereas down there, they expect very little and are incredibly appreciative for what you're giving them."

The families in El Salvador are also more likely to thank God for bringing the American doctors. Even though Austin Smiles is a secular organization and its doctors reflect many different religious backgrounds, Dr. Beckham says the people "are much more open about religious things in Mexico or Central America. The modern idea here is that it must be separated, but most of them are thanking God for us being there. I respond to those things and try to continue in the fact that that's why I'm there because the Lord made it possible."

Not all the patients are children. One man with a grotesque cleft was married with five children of his own. After having his face repaired he said he would go home and kiss his wife for the first time. Another, who was 65, said that after his operation he would get himself a girlfriend-he had never had one. Another man, about 38 and with an unrepaired cleft lip, lived in a smaller village where he met a girl who loved him despite his deformity. They fell in love and married. But he stayed home in their hut while she went out to work because he was ashamed of his face. When he had his lip repaired, he was able to go out and work to support his family.

As Austin Smiles makes progress in the backlog of Salvadoreans needing this surgery, the group has begun to look at expanding to other countries. Recently, Dr. Beckham traveled to Cuba with his church to see if there might be a need for Austin Smiles in that country. He discovered few cleft lips and palates there-and enough local surgeons to do the operations. The Cuban doctors said the reason for the low incidence of clefts was the good nutrition and universal health care available to pregnant women. But one Cuban family practice doctor gave Dr. Beckham another reason: All pregnant women have a sonogram at 20 weeks, and if a cleft is discovered, they are encouraged to have an abortion. Dr. Beckham said, "They don't make them, like in China, but they encourage them, saying, 'We have food rationing and medication rationing, so why have somebody here who doesn't have a better chance of succeeding in life? Why not just abort him?'"

Austin Smiles is proving that these children can have a chance at life. Some doctors volunteer, as Pat Beckham does, out of a desire to serve the Lord: "My whole personal motivation comes out of my missionary experience. I know that 'as much as you've done it to the least of these, you've done it to me.'" Others go out of a more general humanitarian impulse: Jim Fox says, "The reward, I suppose, comes from doing what you know how to do for no other reason than the happiness of doing it for someone who couldn't get it any other way."

But both speak about the miracle of transformation: "Sometimes their mothers aren't sure it's the same kid."