Scaling Up Charity

Smile Train’s Brian Mullaney

Brian Mullaney with a Haitian patient before her surgery this past February. Smile Train has provided roughly 160 surgeries in Haiti and recently launched “Cleft-free Haiti” to completely eradicate cleft there.
Smile Train has been especially active in China. Mullaney met these four nurses from Jinzhong No. 1 People’s Hospital, one of its partner institutions, in 2005.
Smile Train has provided 2,350 surgeries to date in Uganda, where this photograph was taken in 2005.
Pinki Sonkar, whose surgery took place in March 2007, celebrated with Mullaney this past February, the day after <em>Smile Pinki,</em> a documentary about Smile Train's work, won an Oscar.

Against all advice, Brian Mullaney ’81 left a secure Madison Avenue career in 1990 to co-found his own ad agency, targeting the high tech industry. Schell/Mullaney opened with Mullaney and one employee working out of his apartment; the partners were so successful that they sold the firm in six years. Suddenly, Mullaney was free to do anything he dreamed of.

Ever the entrepreneur, he chose to focus on what had been a philanthropic pastime: correcting facial disfigurements in poor children. He became the co-founder of Smile Train, now the largest charity devoted to fixing cleft lip and palate injuries around the world. 

In just a decade, the New York City-based organization has sponsored more than 500,000 surgeries throughout 76 countries, with a primary focus in China and India. In the last fiscal year alone, Smile Train raised more than $100 million and sponsored about 110,000 operations—with only 42 employees. Says Mullaney, “We basically found a better mousetrap, then scaled the hell out of it.” 


Cleft injury, the most common birth defect in the United States, affects one in every 594 newborns, or 6,800 infants per year, according to the Cleft Palate Foundation. Most of these babies receive surgery within three to six months. In developing countries, however, such deformities are far more numerous, and typically go untreated: Smile Train estimates there are 160,000 new cases a year and a 4.6-million-case backlog. 

Though rarely life-threatening, clefts can lead to social ostracism and psychological scarring, as well as severe practical problems: the afflicted children often do not attend school, get jobs, or marry. “A lot of these kids can’t talk, or talk well,” Mullaney reports. “They sound retarded and they are treated like freaks, like the Elephant Man.” Cultural prejudices also abound, some linking the children to evil spirits or Satan, making the condition harder for entire families to bear; in India, Mullaney says, there have even been reports of midwives being paid to smother such babies, especially girls, at birth.

The psychosocial impact of clefts is brought home in Smile Pinki, a 2008 film about the charity’s work in India that won an Oscar for best short documentary (a goal Mullaney had set out to achieve about three years earlier). “These surgeries transform these kids’ lives,” he says. 


Smile Train excels similar charities in sheer numbers not only by applying strict “best business practices” to its work, but by supplanting the traditional medical mission with a more efficient, “less imperialistic” system that has so far trained about 56,000 local medical professionals to perform cleft surgeries. “In the colonial model, foreign doctors get off the plane and act like Jesus Christ—‘Give me your crippled and I’ll heal them,’” says Mullaney. “They push the local doctors to the sidelines, have their press conferences, and then pack up every last Q-tip and leave. This was not only very demoralizing to the local staff, it was wrenching because they would operate on 100 kids, but break the hearts of 300 others. It made me very unhappy. What company turns away most of its customers?” 


Fostering enterprise while correcting a relatively finite, physical problem that has a huge emotional impact greatly appeals to Mullaney, who is both an empathic idealist and a ruthless pragmatist. “We know where the kids are, in every province of every country all over the world. We know what the cure is: it’s a simple, 45-minute procedure that costs donors as little as $250,” he says. “It just seemed so unfair that all these kids were suffering unnecessarily.” With economic conditions improving in many places and more attention being paid to prevention of birth defects (Smile Train also has an educational component), he says that “at this rate, in five to 10 years, we’ll have the backlog well in hand, and have facilities in place to address the new cleft cases in all the developing countries combined.” 

Mullaney first started caring about children with deformities long before his own kids were born. He was working on advertising accounts for Park Avenue cosmetic surgeons, he recalls: “I’d ride the subway to their offices and see all these kids, mostly immigrant and poor children, with giant port-wine stains or a hairy nevus across their face, kids with six fingers, or missing an ear, or a scar that was wide open, or horrible teeth, and I knew my surgeons could fix those,” he says. 

In 1991, while running Schell/Mullaney, he founded a pilot program that offered free surgeries to city kids; ultimately, it grew to include the entire metropolitan school district. Surgeons did the work pro bono, while Mullaney raised funds to cover operating expenses. One day, he saw an article in People magazine about a Virginia-based charity with the same name as his: Operation Smile. He called them up, and by 1994 the two groups had merged to focus on cleft injuries internationally, using two-week medical missions. 

The impact of these surgeries hit Mullaney on his first of many trips to China, when he was allowed to scrub into an operation on a nine-year-old whose name meant Beautiful Cloud. “When she woke up in the recovery room, they brought in a mirror and handed it to her—and I will never forget how her hands were trembling and she stared into the mirror and didn’t say a word, and nine years of tears ran down her face.” He felt he had “witnessed a miracle” and returned to New York “like a man on a mission and began raising millions of dollars for Operation Smile from everyone and anyone I knew.” The exposure to charity work in the world’s poorest corners “fundamentally reset” his values, he says: “I get the bends like a deep-sea diver going between” his two worlds.


Mullaney was so effective that within two years he, Charles B. Wang (his former client at Computer Associates), and DeLois Greenwood (now number two at Smile Train) had boosted contributions to the New York Operation Smile chapter from $60,000 to $1.2 million. Yet with each new mission, Mullaney says he “learned more about how this medical model from 30 years ago was obsolete. The model of ‘teach a man to fish’ is just so much more empowering locally, so much cheaper and more efficient and productive.”

In 1997, he and Wang (who is as high profile in his philanthropies as in his sometimes controversial business practices) devised the idea of Smile Train. Mullaney says Wang, who immigrated to the United States as a boy, still identifies strongly with China and questioned why Operation Smile did not utilize Chinese surgeons. 

Over time, Wang and Mullaney worked with then U.S. and Chinese presidents George H.W. Bush and Jiang Zemin to pave the way for training local surgeons and supporting hospitals in some of that country’s poorest regions. In 1998, they split from Operation Smile and established their own organization. Wang, as chairman of the board, put up the initial $70 million: $30 million of his own, $40 million that he raised from friends. That money, Mullaney’s sweat equity, and their high-level connections put Smile Train on track. 

“Most charities don’t see themselves as a business,” Mullaney says. They “can be terribly managed, pay people poorly, and yet never go out of business. They’re almost like churches; people say, ‘That’s OK, because their hearts are in the right place.’ At Smile Train, we pay people market-rate salaries and if they’re really good, we give them a bonus, and if they’re not, we fire them—we don’t care where their heart is, it can go somewhere else.” 

Also parts of the Smile Train business model: donors are treated like shareholders; doctors are trained via groundbreaking virtual-surgery software that Smile Train helped develop at New York Medical Center; capital investments align with strategic goals (the charity spent $1 million on a digital medical-records system, instead of handling manila folders with more than five million paper documents and photos); surgeons and medical charts/records are rated by outside reviewers to pinpoint problems; and Smile Train holds no direct fundraisers, which Mullaney says are “cost inefficient and wasteful.”

“What we’re doing differently,” Mullaney explains, “is more like franchising the Smile Train operations: financing and working with more than 1,000 local hospitals so that they can do this work themselves.” 

Since the “divorce” from Operation Smile, as Mullaney puts it, Smile Train’s clout and programs have both grown, attracting Hollywood stars and prominent figures such as Colin Powell who provide testimonials and public-service announcements and often also donate to the cause. “One of the advantages I have over other charities is my marketing background,” Mullaney allows. In college, the economics concentrator who liked art and graphics joined Harvard Student Agencies and produced marketing materials for various campus groups, including the logo still used by the Din and Tonics. But he’s also “like a dog with a bone: to be successful in the charity world, you have to be incredibly thick-skinned and determined, or else you’re going to burn out and walk around beating yourself over the head with a stick in frustration.”

He believes in operating a small, focused, creative group of people who brainstorm and daydream to generate “big ideas.” One such session spawned the notion of a feature film about clefts. So much of the health and medical news from “developing countries—malaria and AIDS—is bad news about diseases we still can’t cure, and here you have this little story about something really good that can happen so easily,” Mullaney says. When no one in Hollywood bit, he settled for a documentary. He drew director Megan Mylan (Lost Boys of Sudan) into the cause, just as he had Wang—and they earned an Oscar.

With Smile Pinki’s win, he has refocused efforts on getting a feature film made, with a major star. And with help from surgeon and author Atul Gawande (“The Unlikely Writer”), among others, he studies how to apply the Smile Train model to other conditions with surgical remedies: holes in the heart, club foot, burn wounds, and blindness. “All of these exist throughout the world, are as big as cleft, or bigger, and have interventions that are similarly quick, cheap, and 99.9 percent reliable,” Mullaney explains. “We’re meeting with charities who do this medical work to educate ourselves and think about how to partner with donors.” After a second, he adds: “Once you help 1,000 kids, then you want to help 10,000 kids, then 100,000 kids. In a way, it’s a great addiction to have.”

Read more articles by: Nell Porter Brown

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