This Man Turns “Junk” Into Lifesaving Equipment

Editor’s note: Since Operation Smile’s founding in 1982, delivering safe surgery to people living with cleft conditions in low-resource settings around the world has been – and will continue to be – its driving force.

But as the organisation expanded into more and more places of dire need, it has been met by the devastating effects of hospitals operating with inadequate infrastructure and equipment.

Fuelled by the foundational belief that everyone in need of surgery deserves exceptional care, Operation Smile is applying its expertise in treating cleft conditions to create sustainable solutions that will bring safe and essential surgery to people where it’s needed most.

In rural northeastern Nicaragua, this life-saving work is already underway through a pilot project called Cirugía para el Pueblo – “Surgery for the People.” For deeper context on the problems that this initiative is addressing, follow this link to watch the video and read more. 

Henry Parrales opens the metal gate that leads to a small plot of land behind the primary hospital in Bonanza, Nicaragua.

Just around the side of the building lies twisted piles of what appears to be garbage at first glance.

A closer look reveals that it’s anything but trash.

“Before I started here, they just said, ‘This equipment doesn’t work,’ and the health workers threw it away,” Henry says as he surveys the tangled masses of discarded medical equipment.

Henry Parrales stands among the piles of discarded equipment from the primary hospital in Bonanza. Photo: Jörgen Hildebrandt.

Exposed to the harsh Nicaraguan elements, these devices’ days are numbered. But today, Henry is making sure that no more pieces of critically needed medical equipment suffer the same fate.

As a biomedical technician, Henry is part of a project called Cirugía para el Pueblo – “Surgery for the People.” Supported by the UBS Optimus Foundation, the private/public partnership between Operation Smile and Nicaragua’s Ministry of Health is improving the surgical infrastructure of two primary hospitals and spreading awareness about surgically treatable conditions to the people of Nicaragua’s remote and impoverished north-eastern region.

Henry’s role in the project is to perform maintenance on medical equipment and ensure that each machine is functioning properly.

Between March and September 2018, Surgery for the People’s biomedical team repaired more than 200 pieces of medical equipment, saving more than $316,000.*

For many patients in this area of the country, their survival may depend on the equipment that he repairs.

Henry performs maintenance on hospital medical equipment. Photo: Jörgen Hildebrandt.

In the hospital’s workshop, Henry lends his masterful touch to a piece of equipment that would have likely ended up in the pile behind the building before he began working on the project.

“What I am fixing now is a nebuliser, which is used to relieve children’s breathing difficulties,” Henry says. “We use this daily, especially in emergencies, since the climate here is varied and breathing difficulties are common.”

Every day, Henry applies his knowledge and skill to ensure that the hospitals are the safest possible places for their patients.

He monitors and repairs crucial equipment like defibrillators, which are used to save lives during cardiac arrest. By prioritising neonatal equipment, Henry ensures that the hospitals’ youngest patients receive the care that they deserve.

“Also, I check the operating theatre and the emergency room so that surgery can be safe,” says Henry. “It is my job to check that all of the equipment works perfectly.”

And thanks to Henry, the “junk” that would once be tossed aside is now being turned into equipment that will function as designed: to help save lives.

“I am very happy with my work,” Henry said. “There is less waste and the money can be used to buy medicines and improve other areas.”

Photo: Jörgen Hildebrandt.

* These figures were derived from field reporting and are dynamic and subject to change.

Hope on The Horizon: Safely Resuming Surgery and Care

Eight-month-old Elmehdi, right, 11-month-old Ouissal, centre, and another young patient await their life-changing surgeries at Operation Smile's Women in Medicine: Inspiring a Generation medical mission in Oujda, Morocco, in March 2020. These were among some of the last patients to receive surgery from Operation Smile before medical programmes were postponed due to the COVID-19 pandemic. Photo: Jasmin Shah.

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.

A hallmark of Operation Smile medical missions and care centres is undoubtedly their bustling atmosphere – full of energy and full of people gathered to ensure that our patients get the cleft surgery and care that they need and deserve.

Volunteer medical professionals work side-by-side, quite literally shoulder-to-shoulder, conducting comprehensive health evaluations for scores of patients during a screening day. Those patients and their families, often numbering in the hundreds on large-scale international missions, gather and share stories of perseverance and hope. Care centres’ waiting rooms are filled with the sounds of children playing as they await their consultations.

But the COVID-19 pandemic brought these familiar and vivacious sights and sounds to an abrupt, albeit temporary, end.

In March 2020, Operation Smile made the decision to suspend international travel for medical volunteers and postpone medical missions and care delivery at care centres.

While these decisions were made with the safety of patients, volunteers, staff, their families and communities as the top priority, the postponements have left waiting more than 10,000 patients scheduled to receive treatment.

The organisation quickly pivoted to address many of the pandemic’s novel challenges, such as providing hospitals around the world donations of personal protective equipment (PPE) and providing patients and their communities with food and hygiene supplies as lockdowns stifled livelihoods.

Yet, there is hope on the horizon. Though care delivery looks, sounds and feels much different than before, Operation Smile has resumed providing cleft surgeries in Vietnam, Italy and China. In Morocco and Nicaragua, care centres are once again offering patients in-person care like dentistry, speech therapy and psychosocial care.

The resumption of in-person care offers a glimpse into how medical programmes will be conducted in the COVID-19 era, informing the organisation on how to approach treating patients as conditions improve from country to country.

Dr. Ruben Ayala, Operation Smile's chief medical officer, monitors a patient during a 2014 medical mission in Hanoi, Vietnam. Photo: Zute Lightfoot.

Dr. Ruben Ayala, Operation Smile’s chief medical officer, said that while he stands behind the decision to postpone activity, it’s important to consider the long-term consequences that untreated cleft conditions can cause.

“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,” Ruben said. “The reality is that the longer we wait, the longer more children are going to have difficulty eating, speaking and there will be issues in their growth and development.

“You’re going to have to weigh the pros and cons. We need to step back from the all-or-nothing approach to one that is based on the knowledge that is constantly evolving and the awareness.”

In May 2020, the first Operation Smile country to resume providing surgery was Vietnam, a country that imposed strict lockdown measures at the onset of COVID-19’s spread in neighbouring China. As a result, the country avoided a major outbreak. When the decision was made to host a medical mission conducted entirely of Vietnamese volunteers, there were only around 300 confirmed COVID-19 cases and zero deaths.

Viet Nguyen, the chief representative for Operation Smile Vietnam, said that volunteers are closely following both Operation Smile and health ministry guidelines to reduce the risk of spreading the virus during missions, including mask-wearing, temperature screenings, socially distanced waiting areas and increased sanitation measures.

Patients and their families wait for their comprehensive medical evaluations in a physically distanced waiting area during Operation Smile Vietnam's medical mission in Ho Chi Minh City in May 2020. Operation Smile photo.

“In the past at missions, we would gather about 100 patients and their families; there would be a few hundred of them at the hospital. Right now, we’re only able to bring in about 10 to 20 patients to the hospital each day,” Viet said. “We have to do the screening process as usual. It takes more time, but actually that’s a very good way for us to ensure the safety of our patients, families and also our medical volunteers.”

From May to September 2020, more than 500 patients have received cleft surgery at six Operation Smile Vietnam local missions.

“It’s positive progress,” Viet said. “We feel safe. We strictly follow the guidelines, and we’re making appropriate decisions. We’re actually doing a great collaboration with our in-country partners and also with the headquarters of Operation Smile in the U.S., and we did it at the right time.”

Operation Smile Vietnam volunteer surgeons perform a procedure during the May 2020 medical mission in Ho Chi Minh City. Operation Smile photo.

In Italy, a country that was hard-hit by COVID-19, Operation Smile has also resumed providing surgery and cleft care services at its three Smile House locations in Rome, Milan and Vicenza.

Dr. Domenico Scopelliti, a long-time Operation Smile volunteer cleft surgeon and the director of Smile House Rome, explained that the Italian context differs greatly from that of Vietnam.

“The project here is how to face a journey before the time of a vaccine,” Domenico said. “I very often use terms of navigation, because when we describe our journey, imagine that we’re going from point A to point B and the COVID pandemic moved our boat to point C. The route is totally different – we need to project another route.”

Smile Houses are creating physical pathways that are designed to drastically reduce the risk of the virus entering their facilities, alongside bolstered PPE that includes ventilated surgical helmets.

Dr. Domenico Scopelliti, a long-time Operation Smile volunteer cleft surgeon and the director of Smile House Rome, wears a specialised surgical helmet to prevent the spread of COVID-19 during surgery. Operation Smile photo.
Dr. Domenico Scopelliti, a long-time Operation Smile volunteer cleft surgeon and the director of Smile House Rome, wears a specialised surgical helmet to prevent the spread of COVID-19 during surgery. Operation Smile photo.

Anyone entering a Smile House must have tested negative for COVID-19 within 48 hours of their visit. They then change out of their clothes, place them into a seal bag, and into PPE garments provided by the centre. Entrances and exits are separated, and medical staff change their PPE and fully decontaminate the operating rooms between each patient. Only one parent can accompany a child into the facility, and mask-wearing and physical distancing are practised.

“Timely surgery is very important, because if you do the right job at the right time, you reduce the risk of a patient having functional consequences,” Domenico said. “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 August 2020, Operation Smile also hosted its first two local missions in China. Though the pandemic originated in Wuhan in the country’s east in late 2019, the mission sites of Meigu and Zhaotung are in China’s western region, which was spared the brunt of the disease due to strict lockdowns. Sixty-two patients received surgery at the missions, and four more missions are planned through the end of 2020.

As teams around the world are working within the guidelines of their ministries of health to continue serving patients through telehealth services and nutritional support, our care centres in Nicaragua and Morocco were cleared to reopen their doors to patients for non-surgical services in July 2020.

While the Moroccan team hopes to be able to resume cleft, bone graft and orthognathic surgeries before the end of 2020, it’s been able to provide most of the other services it offers to help patients live more fulfilling lives. Each of Morocco’s centres in Casablanca, Oujda and El Jadida are offering pre-surgical screenings, post-operative care, dental and orthodontic care, psychological and speech therapy workshops and nutrition support.

In the early stages of the pandemic, the Operation Smile Nicaragua team recognised the need to stay connected with its patients by offering them virtual consultations for speech therapy and psychological counselling. Today, they continue to offer virtual care alongside in-person services like speech therapy, psychology, plastic surgery, paediatrics, nutrition, periodontics, odontology and nursing, averaging about 130 consultations per week.

According to Ruben, though COVID-19 will continue to pose challenges for the foreseeable future, those obstacles are surmountable.

“There’s a whole world ahead of challenges, but if we focus on that commitment to children, we will unavoidably become really innovative in how we address the challenge,” Ruben said. “We look forward to partnering with other organisations, to partner with governments, to partner with private entities, 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.”

Help us keep our promise to our patients amid the COVID-19 pandemic. Your support today means we can continue to help them through these uncertain times and provide them with the surgery they deserve when it’s safe to resume our work around the world.

Scenes of Hope: Guadalajara Medical Mission

Photo: Laura Gonzalez.

The programme coordination team for Operation Smile’s February 2019 medical mission in Guadalajara, Mexico, works together to guarantee that every detail of the mission is executed correctly so patients and their families receive the best possible care.

Brian Mejia, left, was a nursing volunteer in 2011 when an Operation Smile medical mission came to the hospital where he was working. He said, “I had never seen a child with a cleft before. I was surprised and asked, ‘what is this?’. I knew from that moment that I could help.” After earning his nursing degree, Brian began working at our care centre in Nicaragua. Two years ago, he moved to Mexico and has worked as a programme coordinator ever since.

Mauricio Rojas, centre, has worked with us for six years as the programme coordinator for Mexico. “What you want to offer to the patients is the best quality of care possible. That means you have to pay a lot of attention to the small details, which is a lot of work, but at the end of the week, it’s all worth it,” he said.

Kristina Grossman, right, has been a member of our international programme coordination team for less than a year, but she has already helped execute missions in India, Madagascar and Mexico. “I find that it’s a privilege and honour to serve our patients,” she said. “They deserve the best medical care we can provide, and it is a joy to serve such resilient individuals.”

Photo: Laura Gonzalez.

Operating room nurse Carol Blackler of Canada checks a patient’s vitals on screening day. During the screening process, volunteers from Honduras, Venezuela, Paraguay, Ecuador, Peru, Guatemala, Bolivia, Spain, the U.S. and Canada came together and screened 196 patients.

Photo: Laura Gonzalez.
Photo: Laura Gonzalez.

Eight-year-old Norma arrives at the medical mission with her dad, Rafael. She had never received surgery to repair her cleft lip because her mum and dad didn’t know that free surgery was available. Norma and her family are members of an indigenous group of people of Mexico living in the Sierra Madre Occidental range in Jalisco known as the Huichol people. Thanks to Operation Smile Mexico’s partnership with the local government, patient recruitment efforts are being implemented and successfully bringing more children like Norma to our missions. Rafael told us that having to travel far from home to reach the hospital made him feel worried. But after he saw the way the medical volunteers treated Norma, he quickly forgot his fears. “After I got to know the hospital and the people, I felt relieved,” he said.

Photo: Laura Gonzalez.

On patient announcement day, a group of mums whose children passed their comprehensive health evaluation listens as they are told what they can expect and what precautions they will need to take to ensure that their child is prepared for surgery the following day.

Photo courtesy of Iván Ramírez.

An incredible group of local women called Las Mamás Gallinas – “mother hens” – provide compassion and support for children waiting to receive surgery. These women also look after our medical team by preparing snacks and drinks for the team so that they can take breaks quickly and get back to treating patients.

Photo courtesy of Iván Ramírez.

While they wait to see a doctor, children have fun at a crafts station set up by Mama Gallinas in order to keep them entertained on screening day. Not only do these dedicated women create an enjoyable experience for the children, but they also calm worried families by reaching out and explaining what to expect when it’s their child’s turn to receive surgery. Mama Gallinas truly bring joy, energy and warmth to each day of the mission.

Photo courtesy of Iván Ramírez.
Photo courtesy of Iván Ramírez.

Patient imaging technician and Mama Gallina Rebeca Flores and patient imaging technician Andrea Duhcan with an infant patient.

Photo courtesy of Osvaldo Godina.

Three-year-old Luna arrives at the hospital with her grandmother, Rocío, who took her in as her own daughter when she was born. “Luna, as you can see, is so sweet and caring. She is so smart, and everyone really likes her,” Rocío said. Luna has faced many hardships during her short life, including being born with a cleft lip and palate, conjoined fingers and without two toes on one of her feet. After receiving cleft lip surgery from Operation Smile when she was 2 years old, Luna returned to receive care for her cleft palate. In August, Luna will start school and hopes to join the girls’ soccer team so that she can make friends with her new classmates. Rocío and Luna’s aunts and uncles have joined together to make sure that she lives a life full of opportunity and happiness.

The story continues in “Scenes of Healing: Guadalajara Medical Mission.” 

Amid the Pandemic, Nairobi Orphanages Face Food Shortages

At 7 months old, Alex was one of the 229 patients who received a comprehensive health evaluation at the medical mission in Nyeri, Kenya, in October 2009. Photo: Margherita Mirabella.

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.

In Kenya, we’re committed to the health and wellbeing of the community in which we work. We recently learned from Operation Smile Kenya’s programme manager, Roy Kariuki, that 335 children relying on five orphanages and children’s homes in Nairobi are facing food shortages as a result of strict COVID-19 lockdowns in the city. That’s why we’re mobilising rapidly to provide immediate relief for these children.

We caught up with Roy to learn more about the emergency unfolding right now in Nairobi.

Roy Kariuki, programme manager of Operation Smile Kenya, helps conduct a post-operative assessment of a young patient during a 2008 medical mission in Nakuru, Kenya, where he served as a programme coordinator. Photo: Keith Bedford.

Q: Could you tell us more about how COVID-19 has impacted Kenya to date? 

A: “As of July 29, we have 18,581 confirmed cases with 299 mortalities (source: WHO Coronavirus Disease Dashboard, accessed July 29, 2020). Experts project our peak to be around late August to early or mid-September. Our health facilities are already overrun by patients, and the government is now directing home-based care for asymptomatic patients and those with mild symptoms. The virus is now firmly in the community. It is difficult to really speculate on the number of people already infected, as our testing capacity is very low. Most government services are still unavailable with employees being requested to stay home or work from home. The private sector has declared unprecedented redundancies. Schools are shut down. The economy is on its knees.”

Q: How are our Kenyan medical volunteers fairing? Are many of them on the frontline of the pandemic? 

A: “We are regularly in touch with our volunteers, and despite hardships of working in very resource challenged environments – lack of PPE, short-staffed hospitals – we are thankful that, thus far, none of our people have been directly affected by the pandemic and we pray it stays so.”

Q: Could you tell us more about our connection to the orphanages and children’s homes to which we are donating? 

A: “I came across the news of the hardships of these five homes through charity and investment clubs that I belong to. Every Christmas or on various holidays, my friends and I would fundraise and buy foodstuffs and clothes for these homes and spend the day with the kids. It was never all at the same time, as we could only afford to do so one home at a time. They are actually many more homes than the five we are focusing on. But at this point in time, I felt it best not to overstretch the resources we have.”

Q: Why are COVID-19 lockdowns preventing these homes from being able to get food for the people they support? 

A: “These homes, even though properly registered by the government through the Ministry of Social Services, rely on corporate and individual donors to feed, clothe, educate, accommodate and provide medical care for the children under their care. With the economy on a downward spiral, companies sending employees home and shutting down their factories, corporate social responsibility initiatives also abruptly came to an end. The homes were left to fend for themselves. When (Operation Smile Co-Founder and President) Kathy Magee learned of their predicament, it was simply amazing how the entire organisation was galvanised into action.”

Q: What has the reaction been from the leaders of these homes been to the promise of our outreach? 

A: “They have been very excited that we have shown an interest. I am collecting lists of their needs so that we can be able to start providing nutritional support next week.”

Q: Beyond providing food and shelter to their children, what other benefits do these homes provide for those who rely on them? 

A: “They provide schooling, accommodation, counselling, psychiatric support and rally sponsorship for higher education. They also find sponsors for kids who require serious medical interventions.”

Q: What would you say to anyone who contributes to this initiative? 

A: “To quote one of the directors at one of the homes – he was an orphan himself, and someone took care of him throughout his childhood – ‘We cannot cure all the ills in this world, but we can certainly try heal the ones closest to us.’”

Q: Could you tell us more about Operation Smile’s work in Kenya?

A: “Operation Smile has been in Kenya since 1987 and is Operation Smile’s second international foundation after the Philippines. We have provided free surgical care to over 10,000 needy Kenyans and provided AHA training to over 1,000 healthcare providers in the country. We are currently in the process of strategising on provision of free comprehensive cleft care to both former and new patients affected by cleft conditions. We are also looking to playing a part in strengthening the health systems in Kenya. Over the last six years, we have been a volunteer resource country for the region as well as for international education and surgical programmes.”

Four-month-old Robert and his mother await his comprehensive health evaluation at the medical mission in Nyeri, Kenya, in October 2009. Photo: Margherita Mirabella.

Going Far Together: A Future for Women in Healthcare Around the World

By Dr. Naikhoba Munabi, plastic surgery resident at the University of Southern California and former Global Surgery Fellow at Operation Smile.

Dr. Naikhoba Munabi, left, stands beside Fouzia Mahmoudi, Operation Smile Morocco Co-Founder and Vice President, centre, and Operation Smile Co-Founder and President, Kathy Magee, during the 2020 March all women's mission in Oujda, Morocco. Photo: Jasmin Shah.

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.

When asked how I’ve been able to climb the ladder of success to where I am today, my answer is always simple: I didn’t do it alone.

I come from a family of physicians, including women such as my mother and grandmother. On the occasions that people have said my race or gender would limit my ability to succeed in my chosen career, I looked to my family to confirm that these opinions were wrong.

My inspiration and support came from outside of my family, too. Female teachers, coaches, lab directors and classmates mentored and helped me believe in my capabilities. Even when I entered the arena of surgery where few women exist, I always had sources of encouragement to continue pushing forward in pursuit of my dreams.

Cleft surgeon Dr. Luca Autelitano of Italy, left, examines a patient with Dr. Naikhoba Munabi. Photo: Lorenzo Monacelli.

Unfortunately, not all women in the world are so lucky.

Almost 1 billion women globally do not have formal employment because they lack access to education, encouragement to continue persevering in a career of their choice, or do not know what a woman can achieve. But 18 million more healthcare workers are needed in the world. It is vital that women enter and continue in medical careers to help address the needs of some of the poorest and most disenfranchised individuals worldwide.

Better mentorship can help get more women into healthcare. Earlier this year during Operation Smile’s inaugural Women in Medicine: Inspiring a Generation medical programme in Oujda, Morocco, 25% of female volunteers said they struggled to find mentorship and guidance in their career despite wanting it.

Team photo of the female medical and nonmedical volunteers during the Women in Medicine: Inspiring a Generation medical mission. Photo: Jasmin Shah.

In male-dominated careers, such as medicine, societal norms are not always encouraging of women. The presence of a mentor can be the difference between a woman entering and staying in healthcare or turning away from adversity.

25% of female volunteers said they struggled to find mentorship and guidance in their career despite wanting it.

Bringing 95 female medical professionals from 23 countries together in Oujda helped establish those critical mentorship contacts. During the programme:

  • 73% of women who weren’t able to find a mentor in their home countries were able to identify one during the mission.
  • 100% wanted to maintain those professional relationships in the future.
  • 97% of women were more confident in their ability to perform their jobs.
  • 100% felt inspired to mentor women in their home countries.
Graph showing how mentorship during the mission had a trickle-down effect for participant home countries. 100% of participants established professional contacts to maintain in the future and 100% felt empowered to mentor working women at home. Graph courtesy of Naikhoba Munabi.

The Women in Medicine medical programme also inspired women to become leaders. Despite only 29% of volunteers having leadership experience with Operation Smile, 93% felt inspired to become a leader in the organisation and 97% felt inspired to become leaders in their home country. Through this desire to lead, 99% of women felt they would also advance professionally and 97% hoped their careers would involve working with other women in the future.

Simply put, creating a collaborative environment for female healthcare professionals encouraged women from all around the world to continue advancing and forging the path for more women to follow.

One of the best parts of being a global surgery fellow has been finding commonality with so many people of diverse origins around the world. The world is brimming with talent, including exceptional female talent. Operation Smile’s female volunteers are role models to other young aspiring and ambitious women in their communities. The women I have met worldwide have been an inspiration to me. The Women in Medicine medical programme was an ode to those female volunteers, their capabilities, their perseverance and their will to care for others.

Help us to continue doing everything we can for patients impacted by the COVID-19 pandemic. When it’s safe to resume surgeries, the support you give today will not only provide more children with the life-changing care they need but enable the next generation of healthcare workers to deliver care where it’s needed most.

Dr. Naikhoba Munabi pictured with volunteers from the all women's mission after completing the cleft surgery simulation workshop. Photo courtesy of Naikhoba Munabi.

About the author: Dr. Naikhoba Munabi is a resident physician in plastic and reconstructive surgery at the University of Southern California. She took two years away from clinical training to work with Operation Smile as a Global Surgery Fellow. During her time with Operation Smile she worked with teams in multiple countries with a focus on sub-Saharan Africa. Dr. Munabi’s public health interests include education, health systems strengthening, and women’s empowerment. Clinically, she plans to continue training to be a craniofacial surgeon.

Surgery for the People: The Need

A single-engine Cessna 208 Caravan is filled to the brim with passengers and luggage, making its way through the clouds, up and away from the busy city of Managua toward Nicaragua’s north-east.

Soon, Lake Managua and the characteristic volcanoes are out of sight and sprawling beneath are hills, rivers, forests and a few scattered villages surrounded by farmland.

An hour later, the propeller plane lands on a strip of gravel in the middle of the town of Bonanza. This is Nicaragua’s Mining Triangle, a remote and rural area known for its mineral resources. Two other towns create the corners of the triangle – Siuna to the south and Rosita to the west.

Here, with support from the UBS Optimus Foundation, Operation Smile and Nicaragua’s Ministry of Health are working together on a pilot project at the two primary hospitals in Siuna and Bonanza called Cirugía para el Pueblo – “Surgery for the People.”

By joining forces, Operation Smile and the Ministry of Health seek to improve the surgical infrastructure of the hospitals and to spread awareness about surgically-treatable conditions to the people of the region.

Patients and families wait to be seen by medical professionals at Hospital Primario Esteban Jaenz Serrano in Bonanza, Nicaragua, one of the two hospitals that will receive improvements to its surgical infrastructure from the Cirurgía para el Pueblo project. Photo: Jörgen Hildebrandt.

“Part of the background is what is happening in the world, where more people die from conditions that are treatable by surgery than by HIV, malaria and tuberculosis combined,” explains Dr. Jordan Swanson, Director of Surgical Innovation and Special Programmes at Operation Smile Nicaragua, a plastic surgeon from the United States who is leading the project.

It all began a couple of years ago when Jordan and his colleagues at Operation Smile travelled to the Mining Triangle to search for people with untreated cleft conditions. Many people in this region live in very remote villages; the closest main road could take hours to reach by walking or by riding horseback, followed by a bus ride of several more hours to reach their primary hospital.

While spending time at the hospitals there, the Operation Smile team got to know the surgeons and anaesthesiologists and saw how dedicated, skilled and committed they are, despite working with very limited resources.

“It struck me that this was a great opportunity for us to partner together with the ministry and really figure out how safe surgery is possible also in an area like this,” Jordan says. “Many people think of us as a cleft organisation; we take care of kids with cleft. I think one can also think of Operation Smile as an organisation that achieves high-quality surgical care. We have more than 35 years of experience figuring out how to create impact and get the job done at the end of the day.”

General surgeons Drs. José Silva and Tyrone Valle consult with a patient at Hospital Carlos Centeno in Siuna, Nicaragua, one of the two hospitals that will receive surgical infrastructure improvements from the Cirurgía para el Pueblo project. Photo: Jörgen Hildebrandt.

And this is where Operation Smile can play an important role in public health.

A few years ago, the Lancet Commission on Global Surgery showed that more than half of the global population lacks access to safe and affordable surgical care when they need it, such as when someone experiences bleeding after childbirth, suffers a burn, develops cancer or is born with a cleft condition. More than 143 million surgical procedures are needed – mostly in low- and middle-income countries like Nicaragua – to save lives and prevent disability, around 5,000 procedures per 100,000 of the population.

“Well, this is very straightforward. In places like Siuna and Bonanza, only about 20 percent of the people in the region are getting the surgery they need,” Jordan says. “Many of them are referred to the capital city hospitals, and that is a tough trip to make and many aren’t going to make it.

“Now, how do we get to the rest of those patients? Part is education, part is equipment and supplies, and part is thinking through how we can connect to the patients and the community and then how to follow up on the outcomes.”

At Hospital Primario Esteban Jaenz Serrano in Bonanza, the problem is tangible. Even though in recent years the hospital has been renovated and refurbished, director Maria Isabel Flores Johnson still has a long list of needs – one being to open another operating theatre. With only one operating room, scheduled surgeries have to give way to emergencies, forcing people to wait for days or weeks. The time spent away from work or family can cause both stress and economic problems for the patient.

Patients and families wait in line at Hospital Carlos Centeno in Siuna, Nicaragua. Photo: Jörgen Hildebrandt.

Improved human resources is another need with the most imminent being the lack of an anaesthesiologist.

“We haven’t been able to hire one because after they finish university, they don’t really like to come here to work,” Maria says. “They want to have a higher salary, better conditions and more benefits.”

Yadive Ríos is an anaesthesia technician and the only person at the hospital qualified to provide anaesthesia. However, the services she is able to provide are limited.

“I can’t help out on paediatric or geriatric surgery, so if we, for example, have an 80-year old patient, he or she needs to be referred to another hospital, which means sometimes travelling almost 400 kilometres to Managua in order to get surgery,” Yadive says.

This also means that whenever Yadive has to miss a day of work, the hospital is forced to cancel surgeries.

“I am the only one here on the staff to do this and they need me, so I ask myself how ill I am on a scale from one to 10, and if I have a fever or a flu, I still go to work,” Yadive says. “But everyone in this hospital makes these kinds of efforts. We are a small hospital and the population has increased a lot these last years, so it is difficult, it can be very dense.”

Yadive shows us the operating ward, where the entire water piping system is to be upgraded to a new and modern one. Co-sponsored by a local mining corporation, it will be the first renovation of the Surgery for the People project.

By hand, she turns on the tap where the surgeons wash their hands before surgery. In most operating rooms, taps are operated by doctors’ feet or knees to make sure their hands remain as sterile as possible. Worse, the water that comes out of the tap is brown and full of mud.

“Our problem with the water is not just that it is unhealthy and not drinkable, but also sometimes that there is no water at all,” Yadive exclaims. “Because it comes directly from the river, it is not cleaned in a water plant, and sometimes there is so much mud in the water that it plugs the entire system.”

As of the publication of this story, anaesthesia technician Yadive Ríos is the only person qualified to administer anaesthesia at Hospital Primario Esteban Jaenz Serrano in Bonanza, Nicaragua. Photo: Jörgen Hildebrandt.

At Hospital Carlos Centeno in Siuna, the situation is just as bad. The lack of proper surgical equipment, operating theatres and staff means that delays and cancelled surgeries are common. Patients who have travelled for days often have nowhere to stay because of lack of beds and wards. Many also arrive with acute illnesses that turn deadly because they never knew that their ailment could be treated by surgery.

“If someone ignores what is an infected appendix, believing it is a parasite, this person will die. It is no one’s fault, it is just the lack of knowledge,” says Dr. Tyrone Valle, a general surgeon at the hospital.

He’s very excited about the project and the education and awareness it will bring for the hospital staff and the community alike. For example, a manual of surgical diseases is being developed, in which the most common surgical diseases are outlined. These manuals will be used at the local health clinics in the remote villages, so people will be able to understand that their condition can be cured by surgery – as long as they visit a doctor as soon as they experience symptoms.

General surgeons Drs. José Silva and Tyrone Valle perform surgery at Hospital Carlos Centeno in Siuna, Nicaragua. Currently, only 20 percent of people in their region receive safe, effective and timely surgery. Photo: Jörgen Hildebrandt.

“When I first came here 20 years ago, we were 20 employees. At that time, there were still armed conflicts here and we received many patients with injuries from guns and pistols, in the stomach or thorax, and injuries by knives because of conflicts over land,” explains Tyrone. “Now, there are almost 200 working here and we have peace in the country, so the causes of death have changed. We don’t have to treat wounds but instead diseases that are curable by medicine or surgery. So, this project can really help people, just by giving them the message that we can treat them and educate them as long as they will come here in time for surgery.”

Scenes of Healing: Guadalajara Medical Mission

Photo: Laura Gonzalez.

Child life specialist Alejandra Canales of Honduras sits with a patient before they receive surgery. Having been on more than 10 missions, Alejandra understands the vital impact that the child life area can have. For many children, arriving at a mission can be a frightening experience, especially if it’s their first time travelling away from home. Child life specialists help those patients relax as they play fun activities with other children who have cleft conditions.

Photo: Laura Gonzalez.

Uriel catches and blows bubbles in the child life area before entering the operating room. Both Uriel and his sister, Diana, travelled to our mission site with their mother, Rebeca, from Mezquitic. While Uriel filled the room with his contagious laugher, Diana was much more reserved with a gentle, creative spirit. She passed the time before her surgery by making bracelets and decorating dolls for the other children.

Photo courtesy of Iván Ramírez.
Photo courtesy of Iván Ramírez.

A local staff member checks the vitals of a patient before they receive surgery.

Photo courtesy of Iván Ramírez.

Cleft surgeon Dr. Humberto Aguirre of Mexico and an operating room nurse from the local hospital work together to perform surgery during the mission in Guadalajara.

Photo courtesy of Iván Ramírez.
Photo courtesy of Iván Ramírez.

Dr. Hector Lino of Mexico works with a surgical resident from the Instituto Jalisciense de Cirugia Reconstructiva to perform surgery on a patient.

Photo courtesy of Iván Ramírez.
Photo courtesy of Iván Ramírez.

Post-anaesthesia care unit nurse Zunilda Dominguez of Paraguay checks on a young patient in the post-operative ward.

Photo courtesy of Iván Ramírez.

Electronic medical records team leader Lorena Arellano gently wakes up a patient after their surgery. For Lorena, attending our mission in Guadalajara was very special to her. “I’m so happy to be back in my country, helping my people. And to be back in the city where I grew up,” she said. Lorena is originally from Guadalajara, but she currently lives in California with her wife, Kristi Loveridge. Her role is very important because our team of doctors, anaesthesiologists and nurses rely on each patient’s medical record to administer medicine and customise their care plan. Lorena hopes to continue to volunteer her time on medical missions for as long as she can. “It’s a part of me that I didn’t know I had. It makes me feel so happy that I found this other side of me that I didn’t know thanks to Operation Smile,” she said.

Photo: Laura Gonzalez.

Uriel rests the morning after his cleft lip surgery as his sister, Diana, prepares to receive surgery on her cleft palate later that same day. At a prior mission, Diana received care from Operation Smile for her cleft lip. Uriel plans to return in a few months for surgery on his cleft palate. They were two of the 109 patients who received safe surgery at our mission in Guadalajara, Mexico.

Photo courtesy of Rodrigo Avina.

Eight-year-old Norma shares her new smile. With help from government workers, she and her father – along with a group of Huichol people from their community – left the mission and made the 13-hour journey back home. Norma looked forward to getting back home so that she could show her mum her smile. We talked to Rafael after Norma’s surgery and asked him what he would do if he saw another child with a cleft condition. He said that he would tell them to come get surgery from Operation Smile Mexico because, “you fix things here.”

Scenes of Hope and Healing: Antsirabe Medical Mission

More than 300 potential patients and their families arrived for screening during Operation Smile’s April 2019 medical mission in Antsirabe, Madagascar. With so few doctors in the country who specialise in cleft and craniofacial surgery, the need for cleft care in Madagascar is great. Photo: Margherita Mirabella.

Adeline with her 2-year-old son, Rindra, left, and Rolland with his 5-year old daughter, Lanto, were one of the families who hoped that their children would receive a free surgery from Operation Smile. The 2019 mission was Rolland and Adeline’s third attempt at getting Rindra and Lanto the life-changing care that they needed.

In 2017, they missed the bus to the mission due to a miscommunication. In 2018, they weren’t aware that a mission was taking place. But Rolland and Adeline never stopped believing that they would have another opportunity. And when Rolland learned about the Antsirabe mission, he walked four hours to the nearest hospital to register both children.

After passing her comprehensive health evaluation, Lanto was placed on the surgical standby list and eventually received surgery to repair her cleft lip. Sadly, due to arriving at the mission underweight and with an upper respiratory infection, Rindra was not cleared for surgery. Hearing that their son couldn’t receive surgery was very devastating for Adeline and Rolland. But after attending the feeding programme that was held during the mission, Adeline’s hope for Rindra grew when she learned important lessons about well-balanced meals and hygiene care.

Rindra was one of 52 children registered in the programme during the mission. And by educating parents like Adeline, medical volunteers hope to see each child arrive at the next mission healthy, strong and ready for surgery. Photo: Margherita Mirabella.

Nine-year-old Marie Angeline, also known as Feno by her family, is one of four children. Her and her father, Daniel, arrived in Antsirabe after travelling 4 hours – by foot – to a bus that took them to the mission site. Feno’s mother, Marie Denise, and Daniel had never seen anyone with a cleft condition before. Both parents were incredibly shocked when Feno was born because none of their other children were born with a cleft. Photo: Margherita Mirabella.

Eleven-year-old Clara smiles widely as she stands among many potential patients. After receiving cleft lip surgery when she was 8 years old, Clara returned to Antsirabe with her father, Dede, for an additional surgery on her cleft palate. Clara had a lovely time meeting new friends and seeing old ones during the mission. Some of the medical volunteers who recognised Clara were thrilled to see how confident and outgoing she had become. Photo: Lorenzo Monacelli.

Feno and Daniel wait with hundreds of other families at the patient village. She was one of 343 potential patients who received a comprehensive health evaluation after travelling long distances by foot, boat and bus to reach the international medical mission.

Daniel told medical volunteers that the reason Feno hasn’t started school isn’t because of her cleft condition. It’s because the closest school is a two- to three-hour walk from their home, and he wants Feno to be a little older before making that long journey. But during the mission, Feno admitted that she’s scared to go to school and would often tell her father, “I don’t want to go to school because I have a cleft lip, and I am not normal.” Photo: Margherita Mirabella.

Anaesthesiologist Dr. Nicoletta Fioretti of Italy examines a young patient’s lungs as part of her comprehensive health evaluation. Photo: Margherita Mirabella.

Anaesthesiologist Dr. Maura Albicini of Italy poses with a young patient and his father during one of the two patient screening days. A total of 13 nationalities, representing the countries of Madagascar, Kenya, Ghana, Morocco, South Africa, Sweden, Finland, Italy, Australia, Colombia, Brazil, Canada and the U.S. came together to provide screening, surgery and post-operative care for patients. Photo: Margherita Mirabella.

Surgeons Drs. Billy Magee of the U.S., left, Valeria Battista of Italy and David Chong of Australia discuss surgical options for a young patient during the second day of comprehensive health evaluations. Photo: Margherita Mirabella.

Daniel and Feno are all smiles as they pose for a photo with plastic surgeon Dr. Luca Autelitano of Italy and anaesthesiologist Dr. Nicoletta Fioretti of Italy. Drs. Autelitano and Fioretti were part of the medical team who helped repair Feno’s smile. With a huge grin, Daniel said that he was “faly,” meaning very happy, with the care that his daughter received from Operation Smile’s medical and non-medical volunteers and staff. Photo: Margherita Mirabella.

Clara calmly sits on the operating room table as the Operation Smile medical team prepares her for additional cleft palate surgery. Patient imaging technician Eli Zakariasy of Madagascar, left, waits to take the facial medical photos that assist the surgeon in completing their work. Photo: Lorenzo Monacelli.

MDG_2019_Antsirabe_000_Marie Angeline Rafenonirina_FTF_Before_001_web (1)

After passing her comprehensive health evaluation, Feno plays in the child life area to learn more about what will happen after she enters the operating room. Through playing with medical props, young patients like Feno see what tools will be used during the surgical process so they won’t be surprised or frightened when they go into surgery.

Friends and neighbours often called Feno, “sima,” a derogatory term for cleft. While waiting for her operation, Feno shared what she was most excited about after her surgery: People will stop calling her “sima” and start calling her Feno. Photo: Margherita Mirabella.

Clara proudly shares her beautiful smile. After passing her comprehensive health evaluation, Clara became one of the 109 patients who received safe surgical care at Operation Smile’s medical mission in Antsirabe, Madagascar. This was Clara’s third surgery that she received, and Dede is incredibly proud of the person that his daughter has become during their journey with Operation Smile.

With dreams of becoming a doctor, Clara hopes to make a difference and help children like herself. Photo: Lorenzo Monacelli.

Advancing Safe Surgery in India: The Durgapur Cleft Centre

Our promise of improving health and dignity during the COVID-19 pandemic endures. We’re helping front-line 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.

In the countryside of West Bengal, India, a neighbourhood in the farming village of Amdole lies on the banks of a pond lined with trees and small brick and clay homes.

A narrow and dusty road winds between the houses, bending toward an expansive stretch of farmland. Ox-drawn carts or motorbikes traversing the town and fields occasionally interrupt the serenity.

Here, 3-year-old Shyam frolics with his siblings and their friends. His loving mother and father, Rahki and Milon, keep a watchful eye on the kids from their clay patio that overlooks the pond.

Though he was born with a cleft lip, which can present many health risks when left untreated, Shyam hasn’t yet experienced health problems nor discrimination from his playmates and neighbours in this tight-knit community.

Regardless, he should have received cleft surgery within the first year of his life to ensure his long-term physical and emotional wellbeing. However, his parents were misinformed by doctors and nurses at the hospital where Shyam was born. They told the parents that he couldn’t receive surgery until he was at least 5 years old.

Three years would pass before Rahki and Milon would learn about Operation Smile India and its cleft centre in Durgapur, West Bengal.

Rahki, Shyam’s mother, and Shyam share a smile at their home in Amdole, West Bengal, India. Photo: Lorenzo Monacelli.

“In the house next door there is a doctor whom we call Rajakaka,” Rahki says. “He said, ‘Tomorrow, there is (an Operation Smile patient recruitment) camp in Murarai. You guys should come with your son.’”

Operation Smile India’s ability to reach Shyam’s parents is the foundation of its approach to improving access to safe cleft surgery for people living in this region’s remote farming communities.

The Durgapur Cleft Center, funded by a grant from the Baxter International Foundation, is housed within IQ City Narayana Multi-specialty Hospital and operates through a partnership with the Inga Health Foundation and the hospital.

While, today, the centre is temporarily closed due to the COVID-19 pandemic, it has provided more than 1,000 surgeries since its opening in March 2019.

During the pandemic and strict lockdowns, which caused immediate and widespread joblessness for daily wage workers, the Durgapur team assembled and distributed packages that provided hundreds of families with enough staple foods and hygiene products to last for two to three weeks. While surgeries remain postponed, teams are also reaching out to patients to learn more about their needs so Operation Smile India can better serve them when the pandemic subsides.

“There is a great need for healthcare here. There are just a couple of decent hospitals. No one is doing cleft care here,” says Abhishek Sengupta, Operation Smile India’s executive director and regional director for India, Russia and Italy. “At the same time, (Durgapur) is a city which is very close to the surrounding states of Jharkhand, as well as other districts in West Bengal where healthcare is even worse than Durgapur.

“It gives us access to a geography which we would not have had we’d been in a city like Kolkata or some other urban city.”

Shyam makes his parents smile as they await his registration at Operation Smile India’s patient recruitment camp in Murarai, West Bengal, India. Photo: Lorenzo Monacelli.

And that access is made possible through a community-focused patient recruitment strategy with the goal of reaching parents like Rahki and Milon whose children need essential cleft surgery and long-term follow-up care like speech therapy, dentistry and orthodontics.

“The way patient recruitment camps work is we have a team here; (they) will normally work with local NOGs and community-based organisations,” Abhishek says. “The reason we use local organisations is because people in that area know them. So, it’s much easier to build rapport and build trust with the patients if we go through them.”

Rahki, Milon and Shyam arrive at the patient recruitment camp in Murarai, which is only about 15 kilometres from their home. The local Lion’s Club hosts the camp, and dozens of patients and their families from surrounding communities arrive to meet with the Operation Smile India team led by Safir Rehman “Mithu” Seikh.

Operation Smile India's patient management coordinator Safiur Rehman "Mithu" Seikh gathers a patient’s information at the Murarai patient recruitment camp. Photo: Lorenzo Monacelli.

“We explain this work (to families). Let’s say a child has a cleft lip. As a result of having a cleft lip, that child will have big problems in school life,” says Mithu, referring to the social stigma that many children living with cleft conditions experience. “If a child has a cleft palate, (we explain) what problems they might face, when should the surgery be done, or if it is necessary.”

The patient recruitment team carefully listens to patients’ parents, gathering detailed information about each child to determine the next steps of their care journey. If they qualify for surgery or cleft care that’s offered by the Durgapur centre, families are given appointments for consultations. Operation Smile India also covers the cost of transportation and food and provides lodging for families at its dedicated patient ward in the hospital.

After their consultation with Mithu’s team, Shyam’s family is elated to learn that their son is scheduled to receive free surgery at the centre the following month. The support they will receive from Operation Smile India makes the more than 5-hour journey and several days spent at the centre possible.

“It feels good to know that, even if it’s so far away, after the operation, my son will be fine,” Rahki says

The entrance of IQ City Narayana Multi-specialty Hospital, the home of Operation Smile India’s Durgapur Cleft Centre. Photo: Lorenzo Monacelli.

The trust that Rahki places into Operation Smile is affirmed through the world-class care delivered by the centre’s staff. The model used by the Durgapur centre differs from most of the other 30 care centres that Operation Smile operates in 16 countries, which are primarily volunteer-driven. Here, Operation Smile India employs surgeons, anaesthesiologists, orthodontists, dentists and speech therapists while utilising nurses and paediatricians through its partnership with the host hospital.

The team’s goal is to provide patients with the complete care that they deserve.

Operation Smile India dentist Dr. Dipanjan Chakroborty examines Shyam during his comprehensive health evaluation at the Durgapur Cleft Centre. Photo: Rohanna Mertens.

“These children need comprehensive care,” says Dr. Partha Sadhu, the Durgapur centre’s lead cleft surgeon. “Because, time to time, the patient needs follow-up, needs necessary surgical intervention, dental interventions, speech pathologist intervention, everything.

“So that is why, other than working as an isolated surgeon, it is always better to work in a team.

Cleft surgeon Dr. Partha Sadhu, third from left, performs cleft lip surgery at the Durgapur Cleft Centre while surgeon observer Dr. Radha Pranbu, second from left, watches and surgeon observer Dr. Gunjan Agarwal, right, assists. Photo: Lorenzo Monacelli.

Abhishek adds: “You have to keep following up. A child might need two or three surgeries. A child almost always needs prolonged speech therapy. You need orthodontic care, because, many times, you need to do a lot of work with the facial bone structure before the child is even ready for surgery. A lot of these kids are malnourished, so we need to have a proper nutrition programme so the child is healthy enough to get surgery.

“You need to provide comprehensive and complete care from the cradle until the end of growth.

Abhishek Sengupta, Operation Smile India’s executive director and regional director for Inida, Russia and Italy. Photo: Lorenzo Monacelli.

After a month of anticipation, Shyam’s family arrives at the centre. They settle into the patient ward before his comprehensive health evaluation begins. Shyam is found to be in good health and is placed on the schedule for surgery.

After an operation that lasted around an hour, the course of his life is forever changed.

This is just the beginning of Shyam’s care journey, the centre is also poised to continue to grow once the COVID-19 pandemic subsides. Plans are in the works for strengthening its community outreach programmes beyond patient recruitment to bring nutrition programmes, speech therapy, post-operative care and, eventually, surgeries even closer to families like Shyam’s.

“When we started this, we wanted to start small with the centre. We started by advancing safe surgery, then we started adding the other components,” Abhishek said. “The next step is taking things to the community – to connect the last mile for our patients.

Rahki embraces Shyam after his cleft lip surgery at the Durgapur Cleft Centre. Photo: Rohanna Mertens.

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.