Smile Train (1999–)

Smile Train is a non-profit organization that Brian Mullaney and Charles Wang founded in 1999 in New York City, New York, that provides resources and trains medical staff in over ninety countries to give free surgeries to children in need of cleft repair. Clefts are birth defects that affect one in 700 children all over the world. They occur when the roof of the mouth, or palate, the lip, or both have a gap or split, because the tissues and bones did not fuse properly during fetal development. Surgeons typically repair clefts within the first year of life because clefts can often cause problems with eating, speaking, breathing, and hearing. Beyond providing cleft surgeries, Smile Train also supports the needs of children with clefts with services such as speech therapy, dental care, and psychological and nutritional support. Smile Train helps provide better access to cleft surgery and care for thousands of children worldwide, which improves the quality of life for people born with the developmental condition.

Prior to creating Smile Train, Mullaney started another cleft charity, Operation Smile, in the early 1990s. Mullaney, who graduated from Harvard University in Cambridge, Massachusetts, co-founded an advertising agency in New York City, New York, in 1990 that targeted the tech industry. According to Harvard Magazine, while Mullaney was working on advertising for cosmetic surgeons, he would often note children on the subway with various birth defects and thought he could assist them for possible surgeries due to his connections. Mullaney noted in an interview with the organization Asia Society, which works to connect the West to Asia through various forms of education, art, and policy, that cleft surgeries are relatively cheap, quick, and can dramatically improve many aspects of a child’s life after one operation, and because of his job, he knew surgeons who could treat the children’s defects. So, in 1991, while working at his advertising company, he began raising funds to cover the operating expenses and recruiting surgeons he knew to provide free surgeries to low-income kids unable to afford the procedure. In an interview with The Virginia Pilot, Mullaney spoke about the program and explained that it connected cosmetic surgeons with low-income children who had facial abnormalities. Mullaney called the project he was working on Operation Smile.

After naming his initiative in 1991, Mullaney learned about another cleft charity named Operation Smile based in Norfolk, Virginia, which funded surgeons’ trips to perform free cleft repair surgeries internationally, and in 1994, the two organizations merged. Bill Magee, a plastic surgeon, and his wife, Kathy Magee, who was a nurse and clinical social worker, founded Operation Smile in 1982. Both Operation Smile organizations became one in 1994. One of Mullaney’s previous clients from the advertising agency, Wang, helped boost Operation Smile’s New York branch. Wang was the founder of Computer Associates Technologies, a company that sells computer software, and was a minority owner of the New York Islanders, which is an ice hockey team, as well as a real estate owner and developer.

Mullaney started going on Operation Smile missions throughout Asia around 1994, and his experiences there caused him to develop and propose a new model for Operation Smile. In his proposed model, rather than flying volunteer doctors and equipment to countries in need, the organization would help train local doctors and health professionals to perform cleft lip and palate repairs, and it would pay them for the surgeries they performed. According to The Virginia Pilot interview with Simpson, Mullaney believed that supporting local hospitals and medical professionals was a more sustainable and self-sufficient model that is also safer and cheaper than medical mission work. However, Operation Smile remained focused on sending surgeons and volunteers from the US to countries in need for several more years.

Mullaney and Wang worked with Operation Smile during most of the 1990s, but in 1998, they split from Operation Smile. In 1999, they founded Smile Train, which adopted Mullaney’s model, which Smile Train called their teach a man to fish model, based on the idea that it is more sustainable to teach someone how to do something than to provide it for them. According to Mullaney, Operation Smile’s model of US surgeons providing free surgery in countries such as the Philippines began to breed dependence on the US surgeons. For example, he explains in his blog that after organizations like Operation Smile, surgeons from the Philippines became less likely to operate because a US surgeon would do it for free, and the parents of children with clefts preferred the US surgeons to operate. In Mullaney’s blog, he shared that oftentimes, when Operation Smile went on their two-week medical missions, hundreds of children would show up hoping for free surgery, but the organization could not provide surgery for them all. Additionally, during those missions, Mullaney witnessed children die from what he called avoidable and catastrophic events because of the pressure placed on US physicians to perform as many surgeries as quickly as possible. Mullaney explained that he struggled when witnessing that, and the events motivated him to create a surgical charity that would empower local surgeons by giving them the training and financial support to increase their surgical success and independence and turn no child away from an operation they needed. Thus, he created Smile Train, and its new focus better supported building up healthcare infrastructure around the world.

During the creation of Smile Train, they developed an electronic patient database called Smile Train Express to monitor the care and surgeries they provide and analyze trends in their patient populations. On Mullaney’s blog, “2 Million Smiles,” he elaborates on the Smile Train model of empowering surgeons in developing countries and describes how the Smile Train Express database ultimately tracks the organization’s success around the world. By using the database, Smile Train can keep an electronic patient chart of every surgery that it funds, which also allows the organization to hold the surgeons they paid accountable for the surgeries they claimed to be doing. Smile Train surgeons must meet qualifications such as certification as a maxillofacial or plastic surgeon in their country, registration in Smile Train Express, and demonstration of quality in cleft surgery.

To expand on the safety and quality monitoring of Smile Train Express, one of the cleft surgeons on the Medical Advisory Board for Smile Train offered to grade the cleft surgeries based on the result of the procedure. According to Mullaney’s blog, grading the surgeries was difficult since the surgeon had to take the severity of the cleft, and any prior cleft operations into account. Mullaney explained that the grader put a system in place to review photos from before and after the procedure without knowing which surgeon performed it or the country where the surgery occurred. That system allowed Smile Train to provide quality ratings for every surgeon who was participating in the program, which allowed for more customized training and education. Smile Train found that the surgeons in developing countries were performing a high volume of surgeries due to the high local demand for cleft operations, which gave them an immense amount of practice. The quality ratings for the volunteering surgeons from the US that work with Smile Train were often lower than the local ones in developing countries because they had many opportunities to practice and develop their skills.

In 2008, Smile Train produced Smile Pinki, a documentary film about a young girl in India living with a cleft lip, which won an Academy Award for Best Short Subject Documentary. The film primarily tells the story of Pinki Sonkar, a patient who receives cleft surgery after facing discrimination for her cleft lip. The film also features Ghutaru, another child whose cleft affected his speech and kept him out of school before he received a cleft surgery. The documentary spreads awareness on the difficulties that children with clefts face and displays how organizations like Smile Train offer cleft surgery to children in the developing world who could otherwise not afford it.

Then in 2011, Smile Train and Operation Smile announced a merger of the two cleft charity organizations, but the merger never actually occurred. According to The New York Times, the goal of the merger was to help as many children with clefts as possible. However, their differing business models and financial disagreements caused conflict that ultimately prevented the merger from occurring. The New York Times also states that Smile Train donors and board members were not in unanimous approval of the decision to merge the two cleft organizations.

According to The New York Times, in 2012, Mullaney and Wang disagreed on where to allocate financial resources within Smile Train, after which Mullaney left the organization. Mullaney pushed for expanding Smile Train’s mission to perform operations repairing other abnormalities such as burn scars or club foot, which is a birth defect where the foot develops in a twisted position. However, Wang did not agree with pursuing operations for those other missions within Smile Train. Mullaney left Smile Train in 2012 and began to pursue a way to treat other birth defects in need of treatment. According to GlobeNewswire, that year, he co-founded another charity organization, WonderWork, which focused on providing surgeries and treatments for children with clubfoot, burns, and blindness.

As of 2023, Susannah Schaefer is the President and Chief Executive Officer of Smile Train, where she leads the organization in its efforts to increase healthcare access as well as the capacity of cleft care globally. Before Smile Train, Schafer worked for Wang in various positions, such as Special Assistant to the Chairman and CEO at Computer Associates, which is now called CA Technologies, and according to Smile Train joined the organization in 2013. Smile Train also has a Medical Advisory Board that is comprised of global cleft experts and other medical professionals who set safety standards for Smile Train’s medical partners. As of 2023, Larry Hollier, a cleft surgeon who is the Surgeon and Chief of Plastic Surgery Service at Texas Children’s Hospital in Houston, Texas, and who works as a Professor of Plastic Surgery at Baylor College of Medicine in Houston, leads the medical advisory board members.

Under Schaefer’s leadership, Smile Train has made many technological innovations such as virtual surgery simulators, which provide additional support to surgeons for proper cleft lip and palate care. Smile Train’s Virtual Surgery Simulator, launched in 2013, is an interactive, open access, surgical training technology that assists surgeons learning surgical techniques to repair cleft lip and palate. That resource uses interactive animated graphics, written and oral instruction, and video footage of surgical operations to provide detailed instruction on how to perform cleft repairs. Additionally, in November 2020, Smile Train partnered with Simulare Medical to create The Simulare Cleft Lip and Palate Simulators. The simulators are three-dimensional printed, lifelike oral cavities that surgeons can use to practice on and prepare for surgery. Smile Train offers the simulator as a part of a comprehensive training kit or an individual unit, allowing surgeons to get a realistic training experience.

Smile train has also created speech therapy mobile applications to provide further access to cleft lip and palate care. One of the mobile applications created is a speech therapy service called Smile Train Speech Games and Practice that people can download through Apple and Google to engage children with cleft lips and palates in speech therapy. The application includes games, songs, and stories for children with speech problems related to cleft, thus, it increases accessibility to speech therapy services for patients and their families. Along with the mobile application for patients, which is available in both English and Spanish, Smile Train developed an application in Spanish called Smile Train Terapistas for speech providers to track patient progress throughout their care.

Additionally, Smile Train has elevated the standard for cleft care in developing countries by providing surgeons opportunities for hands-on training, virtual training, and participation in conferences. For example, Smile Train organizes one-on-one and small group training programs for hands-on quality training. The organization has also created virtual training simulators that can provide instruction for cleft lip and palate repair to users across the world. By 2017, Smile Train had already supported over 30,000 opportunities for academic and professional training at conferences and often with organizations such as the American Society of Plastic Surgeons, the Plastic Surgery Foundation, the International Cleft Lip and Palate Association, and the American Cleft Palate-Craniofacial Association. As of 2023, the organization still focuses on having local and regional trainers lead the hands-on teaching as a part of their teach-a-man-to-fish model.

As of 2023, Smile Train partners with various corporations, which increases their social impact and funding to help them provide children worldwide with the care they need. Smile Train’s corporate partnership programs engage their partner’s employees with the Smile Train mission and create campaigns to promote the goals of both organizations. Furthermore, many celebrities actively support Smile Train’s mission. For example, Paula Shugart, president of Miss Universe Organization, and Crystle Stewart, president of Miss USA Organization, joined the Smile Train Board of Directors to help increase public awareness of global cleft care.

Smile Train has supported over 1.5 million cleft surgeries in over ninety countries as of 2023, which has earned the organization recognition as a successful nonprofit. From 2016 to 2022, GreatNonProfits, a platform that reviews nonprofit organizations in the US from peoples’ experiences, dubbed Smile Train as top rated with 4.5 out of five stars in 2022. The charity also earned the 2022 Platinum Seal of Transparency from Candid, a website that distributes information about US nonprofits and awards the Platinum Seal to charities based on their strategies, goals, and progress metrics. Charity Navigator, another service dedicated to evaluating community service and nonprofit organizations, gave Smile Train a score of one hundred percent.  

Smile Train’s model encompasses many components of cleft care, and the organization has provided services beyond surgery from the beginning. Cleft surgery has been and, as of 2023, continues to be the focus of Smile Train, but patient experience also depends on the support, counseling, and assistance in understanding a cleft diagnosis. Additionally, Smile Train has provided children with clefts opportunities to get various forms of care such as dental, orthodontic, and psychological care while also improving their speech and learning about proper feeding and nutrition.

Since Smile Train’s founding in 1999, the organization has empowered local healthcare professionals to provide cleft care all over the world so that children are not left without care after US doctors return home from their medical missions. According to their website, Smile Train chooses to focus on clefts due to the permanent, immediate, and dramatic effect that a cleft surgery has on a child because once a surgeon treats cleft lip, it never comes back. Smile Train’s vision is to ensure that children with clefts have everything they need to not just live but thrive. As of 2023, Smile Train continues to raise awareness for clefts and helps to improve the lives of children with clefts by providing essential surgery and care to support them in their future.