All Commentary
Saturday, May 1, 1993

Operation Smile

Operation Smile will continue to prove—both at home and abroad—that the most effective charity is not coerced by governments but is freely given by individuals.

D. K. Brainard is a student at Hillsdale College in Hillsdale, Michigan.

Eugenia Pop bursts into tears as the men lead her daughter away. But while there is fear in her eyes, Eugenia’s tears are tears of hope. Twelve-year-old Carmen is about to undergo reconstructive facial surgery at the hands of a visiting team of American surgeons at Budimex Hospital in Bucharest, Romania.

For the doctors of Operation Smile International, a group that has been taking its medical expertise to children around the globe since 1982, the three-hour operation to repair Carmen’s face will be routine. But for Carmen and her mother, Operation Smile is an answer to prayers after a decade of seeking treatment under Romania’s centralized health care system.

Carmen Pop was only 11 months old when a rare disease attacked the right side of her face and left an ugly hole in her nose and upper lip. After two operations at the age of 3 were less than successful, she was dismissed as untreatable by doctors in the small border city of Arad where she was born.

For the next decade, Eugenia and her husband Vasile exhausted all of their resources trying to find someone who could help their daughter. They tried petitioning the government; Carmen was placed on a priority list at the Health Ministry in Bucharest, but the years passed and nothing more was done.

In 1989, a church medical group in Arad raised enough money to send Carmen to a hospital in Germany where she could be treated by expert plastic surgeons. But the Romanian government refused to grant the Pops a temporary travel visa.

Then, soon after the December 1989 revolution that swept strongman dictator Nicolae Ceausescu from power, a visiting American physician stumbled across Carmen and referred her to a doctor in Bucharest. The field director for an American humanitarian organization, Dr. Solbritt Murphy was instrumental in securing permission for Operation Smile to set up shop at Budimex, where they would spend ten days performing free surgery on deformed children.

“All these years we had hope in God that Carmen could get treatment in a Western country,” Eugenia says through her tears. “We hope that God has finally looked upon us.”

Unlike many other Romanian children whose only hope for a cure lies in the hands of foreign volunteers, Carmen Pop’s ordeal is uncommon because it will have a happy ending. Three years after the bloody Christmas revolution that promised an end to the totalitarian era, Romania’s national health care system still teeters on the brink of total collapse. As AIDS and other epidemics ravage the nation’s young, Romanian physicians have their hands tied by a lack of manpower and supplies.

When Nicolae Ceausescu seized power in 1978, Romania could boast about 1,000 trained surgeons. But by 1990, “they had 500 trained surgeons left for a population of 23 million,” says Dr. Murphy. “He discontinued training for virtually all human services.” Bucharest’s sole nursing school graduates 400 nurses each year, while one prominent pediatric surgeon estimates that hospitals in Romania have a collective shortage of 7,000 nurses.

The list of essential supplies that Romanian doctors do without is seemingly endless, from modern technology like X-ray machines and anesthesia monitors to simple items like surgical gloves, compresses, and hypodermic needles.


The Health Ministry’s Paralyzing Grip

While American politicians from both parties clamor for a federally regulated national health care system in the United States, it is worth noting that Romanian physicians blame much of the malaise that grips the medical profession in their country on 50 years of Communist central planning.

Romania is obviously an extreme example of the ills of socialized medicine; the demise of the Romanian health care system was greatly exacerbated by the bizarre totalitarian policies of the Ceausescu regime. But a look at just how bad things have become there should be enough to remind us that any move away from a free market approach and toward a centralized system will prove detrimental to the quality of medical care available to the consumer.

For the first time in a half century, Romanian doctors enjoy the freedom to speak without fear about the counterproductive and often destructive nature of the system they have labored under for so long. Their observations are frank, angry, and urgent, propelled by the frustration of years of enforced silence.

Dr. Nicolae Dirina, director of Budimex Hospital, is playing host to Operation Smile while the team is in Bucharest. Dirina pulls no punches when discussing his country’s predicament.

“The Health Ministry still organizes everything,” says Dirina. “We don’t need different employers from the Ministry of Health to tell us what to do.”

Dirina says that since the revolution, he has often been offered special deals from Western medical supply companies eager to do business in Romania. “They say if we will buy something—anything—from them at a reduced rate, they will give us presents, machines, and other things we desperately need,” he says.

But the budget for his hospital is administered by the Health Ministry and Dirina says he doesn’t know how much, if any, money he will receive each week. “It’s not enough to buy even needles,” he says sadly.

Romanian doctors blame epidemic levels of AIDS and other diseases, especially among the young, on the fact that doctors are often forced to re-use dirty syringes. “In your country you use it once and throw it away,” says Dirina heatedly. “We sterilize it and use it again and again and again.”

Budimex Hospital squats along a dirty street on the north side of Bucharest, sandwiched between rows of crumbling tenements that stretch nearly half a mile in either direction. Despite the squalor of its surroundings, Budimex is the largest and most respected pediatric hospital in Romania and is the leading center for surgical training in the country.

“Things are worse in all other hospitals in Romania,” says Dirina.

Mike Erricos, an orthopedic surgeon at Cornell University’s North Shore Orthopedic Hospital, is on his first Operation Smile mission. Erricos is appalled at the conditions under which the Romanian doctors are forced to operate. The Romanian government “eliminated all knowledge in 1978,” he says. “They consciously put themselves back in the Stone Age.”

Dirina’s Romanian protégé, Dr. Sebastian Ionescu, says it is inevitable that the quality of medical care will decline under a system which offers no incentive for good performance and requires doctors and nurses to work for low pay (doctors earn about US$30 per month, about the same as the average government employee) in primitive conditions, their hands bound firmly with red tape.

In fact, Dirina says, every facet of a doctor’s professional life is controlled by the Health Ministry. Doctors are often not allowed to choose the field in which they wish to specialize and managers are forced to work with whomever they are sent by the government, rather than being allowed to recruit and train outstanding young physicians.

As a result, many doctors still practice medicine the same way they did a half-century ago, unmotivated to sharpen their skills and unreceptive to surgical advances and innovative practices, Ionescu says.

Erricos stumbled across the fruits of this kind of thinking when he noticed that many young children in Romania are afflicted with a peculiar deformity that causes their knees to stick permanently in the wrong position. After doing some investigating, he discovered that many Romanian physicians treat malnourished infants by injecting their thighs with massive vitamin doses.

Since the children’s legs are not developed enough to support the injections, the shots often cause irreversible nerve damage, crippling the children for life.

“These kids are malnourished,” says Erricos. “The Romanians seem to think malnutrition is a disease and they try to treat it with vitamins. I am knocked over by the number of cases I am seeing.

“This is not malicious. This is ignorance.”

Dirina says doctors administer the injections because they cannot afford to buy oral or intravenous drugs. “We were obliged to administer these drugs intramuscularly and this problem will continue until we have those [alternative] drugs,” he says.

But Ionescu says that even when modern treatments do become available, doctors often will not use them because they are too proud or lazy to change their ways. “I can tell you if I am honest that things are continuing the same way in this hospital,” he says, shrugging his shoulders. “So [the children] will be handicapped.”


Exporting the American Dream

Contrasting the attitude of resignation shared by these Romanian doctors with the energy and optimism of Operation Smile founder William Magee throws into relief the ideological differences between the free market system and socialized medicine. While the Romanians have spent their careers fighting past barriers erected by their own government, Magee has enjoyed the freedom and the means to spend the last decade bringing miracles to children like Carmen Pop–in essence, exporting the American Dream.

The seed that would blossom into Operation Smile was sown back in 1981 on a commercial airliner somewhere between the Philippines and Norfolk, Virginia, where Magee operates a successful practice as a plastic surgeon.

Magee and his wife Kathy, a clinical nurse, had been invited to the Philippines by a friend for a week of surgery on children with cleft lips and palates. The family accepted the invitation, unsure of what to expect from the trip. What they found was a ragged army of children with facial deformities thronging the team’s base hospital, hoping for a chance to be seen by the American doctors.

When the week was up, Bill Magee recalls, he and his friends had operated on more than 100 children. Yet they had to turn 200 more away. Touched by the incredible need and openness of the Filipinos they met, the Magees decided on the airplane home that one trip was not enough; like General MacArthur, they vowed to return and help those they were forced to leave behind. In the next two years, the family flew back to the islands twice, each time asking friends and friends of friends to come along and help.

In 1982, the Magees officially christened their work Operation Smile International (OSI), symbolizing the sunshine their efforts brought to the faces of the deformed children they treated. Since then, more than 1,200 doctors and health care professionals have joined the Magees as OSI volunteers, treating more than 4,000 children in countries as diverse and far afield as China, Liberia, Colombia, and Vietnam.

In effect, Operation Smile represents the surplus of the American system. While the organization occasionally receives government grants, it gathers most of its $2 million annual operating budget from individual and corporate contributors. (According to OSI documentation, government contributions accounted for five percent of the fiscal 1990 budget and zero percent of the fiscal 1991 budget.)

In addition, each OSI volunteer is required to help pay for his or her trip and to help collect supplies that will be used on the expedition. And the giving of these volunteers is not limited to the occasional relief trip. In 1991, OSI doctors treated more than 2,900 American children for free.

Dr. Frank Yeiser, a veteran of six Operation Smile missions and a longtime friend of the Magees, sums up the attitude that has made the organization so successful. “If you tell me it can’t be done, that’s the wrong answer,” he says.

The can-do attitude of the American doctors quickly becomes apparent at Budimex. Team co- leaders Yeiser and Dr. Thomas Lawrence had planned to devote the bulk of their time to surgery on children culled from the infamous state orphanage system. But because of bureaucratic bungling, only about half the expected number of orphans has arrived at a pre-surgery screening session.

The American team reacts quickly, sending word through the hospital and a network of American and French relief workers that they have room for more children. Volunteers are sent into outlying villages to search for potential surgery candidates.

One child who turns up in the dragnet is three-year-old Cristian Ispasioana, a towheaded boy with a cleft palate. Cristian’s mother is astounded that the American surgeons would actually seek out children to operate on.

“How can a U.S. man have the pleasure to operate on Romanian children for free?” she asks through an interpreter. Upon meeting members of the team, her joy deepens. “I am very happy with the American doctors,” she says. “Romanian doctors don’t play with the children. The Americans are more happy and they speak differently to the children.”

The difference in attitude between the Americans and their Romanian counterparts is glaringly obvious. While the Romanians are competent and eager to help out around the operating tables, many of the older doctors exude a palpable sense of disillusionment. Their eyes have the flatness of those who have been disappointed too often to gamble on hope again.

“I get the feeling the Romanian physicians feel very frustrated because they have been left out of the medical mainstream,” says Lawrence, whose day job is overseeing the University of North Carolina’s Plastic Surgeon Training Program. “I think the greatest effect we can have here is letting people know that we care.”

Magee concurs. “The Romanian people, as I see it, need an uplift,” he says. “If we can be the spark that gets a [medical] revolution going, then we have done what we wanted to do.”


Rebuilding Through Private Effort

While much of the Romanian medical corps has gone limp under the straitjacket of the Health Ministry, there are doctors who have struggled against the system and the mediocrity it breeds, brilliant surgeons like Ionescu, who has campaigned publicly for privatization of the health care system despite the fear of reprisals by the state.

And there are stalwarts like Alexandru Pesamosca, 63, President of the Romanian Pediatric Surgical Society. A large, energetic man, Pesamosca has personally trained many of Romania’s pediatric surgeons. The most renowned physician in the country, Pesamosca has remained true to his own standard of excellence despite a lifetime of professional adversity.

But in a system that strives for mediocrity, excellence demands sacrifice. Until the revolution, Romanian doctors were discouraged from attending Western medical conferences and were taxed so heavily on foreign medical texts that knowledge of modern medical advances was almost inaccessible. But Pesamosca is fond of recalling how he once disdained government regulations to attend a symposium in Vienna, Austria, forced to travel with only a ham sandwich and the equivalent of two U.S. dollars in his pockets.

For years Pesamosca has dreamed of building a modern pediatric hospital on the grounds of Budimex. Although it seems to him that the U.S. $50 million it would take to build the complex might as well be lodged on the moon, Pesamosca refuses to abandon hope, using the looser atmosphere of the post-Ceausescu era to seek help from U.S. and European medical supply companies.

Fifty years of central planning has endowed the Romanians with a keen distrust of government. Although the Bush administration gave Romania $64 million in foreign aid in 1990, Dirina says that his government would rather spend the money on military equipment than on needles or X-ray machines.

When the Romanian government receives aid earmarked for medical relief, Dirina says, the hard currency goes into the coffers of the Health Ministry. But when the Health Ministry doles out funds to his hospital, it is invariably in Romanian lei, which is practically useless on the international market.

With recent elections bringing the country closer to a non-Communist coalition government, the Romanians sense a wind of change stirring over the horizon. But the doctors know that here, as in other former Eastern-bloc countries struggling to throw off the mantle of Communism, things could get much worse before they start getting better.

In fact, the belt-tightening has already begun. In 1991, the ruling Council for National Salvation announced 30 percent across-the-board staffing cuts in all health services.

So for the future, doctors say the best cure for their ailing hospitals, clinics, and orphanages will be the efforts of private groups like OSI and the volunteerism of people like Bill Magee, Frank Yeiser, and Tom Lawrence.

“In my country we have a proverb,” Pesamosca says of life under Communism. “We expect the Americans to come at the first and the fifteenth of the month. I think now it is necessary to change what is a very difficult situation. To change, it is necessary that you are here.”

Operation Smile’s ten days at Budimex will not be the organization’s sole contribution to the healing process. OSI is helping to sponsor a team of physical therapists who will rotate on six-month shifts, working with Solbritt Murphy to rehabilitate disabled orphans. But like their hosts, Operation Smile doctors look forward to the day when Romanian physicians will no longer be the orphans of the European medical community. “We’d like that,” says Yeiser. “The ideal goal would be to put yourself out of business.”

In the meantime, Operation Smile will continue to prove—both at home and abroad—that the most effective charity is not coerced by governments but is freely given by individuals. In the words of Tom Lawrence, “To repair a small child’s deformed face is to give that child a special freedom. And that is what America and Americans are all about.”