TRANSFIGURATIONS With a surgical team in Mexico.

It's been said if one wants to see the face of God, look at the simple beauty of a child. But what if that face has been deformed by a cleft lip, or burn scars stretch over its surface? Can we find God's handiwork manifest in such grotesque accidents? And how ought we to respond?

In February my wife and I were privileged to participate in a trip to the interior of Mexico with a group known as M.O.S.T. (Mercy Outreach Surgical Team). Fourteen physicians, sixteen nurses, and eighteen support personnel journeyed from San Diego, California, to Uruapan, about two hundred miles west of Mexico City in the foothills of the Sierra Madre Occidental mountains. We had three plastic surgeons, three orthopedists, a urologist, a general surgeon, and five pediatric anesthesiologists. I was the internal medicine "sweeper." My job was to deal with complications, such as fevers, unexpected heart murmurs, pulmonary congestion, or in one case, a collapsed lung. But I was also pressed into service to spell assistant surgeons or nurses who needed a break. And sometimes I simply washed instruments or just held crying babies to soothe them on the way to the operating room. My wife worked in post-op. Even though she's been out of professional nursing for several decades while she's raised our children, her experienced calmness in dealing with sick patients who were vomiting, or spitting up blood, reassured the lay volunteers assigned to the area with her.

The idea for M.O.S.T. originated in 1987 when a group of nurses from Mercy Hospital (now Scripps Mercy) in San Diego formed teams to travel to the interior of Mexico to operate on children with various deformities. There are many such volunteer groups scattered around the United States, and while M.O.S.T. may be among the best, it's not unique. Its operation, however, is complex. First, members of the San Diego Rotary Club scout appropriate locations, politick for local support, and provide financial assistance. Then twice each year the team flies off to Mexico and spends a week operating on children who have been brought in from the impoverished countryside.

On a typical day, everyone rises at 5:30 a.m. to get to the hospital, operates until 7 or 8 p.m., goes back to the hotel for a bottle of cervesa and collapses until the next morning. At Uruapan the team did 217 procedures in four days, ranging in severity from simple repair of cleft lips to complex flap rotations for burn scars. That's a month's work for an average-size general hospital in the United States. Members of the local Rotary Club arrange for hotel accommodations, and every day club wives outdo one another to prepare lunches for the group. The last night before departure, they treat team members to a colorful fiesta with lots of music, demonstrations of local dances, and sampling of various tequila drinks so that the spirit of camaraderie infects even the most shy. Indeed if there is any risk for the crew it's not hardship but pride because team members are treated like celebrities, with TV coverage, gifts, and community adulation.

What lessons do the visits teach? First is the value of teamwork. While the focus is on the efforts of the plastic surgeons and pediatric orthopedists, they would fail without the contributions of every person on board, and the institutions back in the United States. Furthermore, the Mexican government has to be enlisted to give its ongoing support. Then local doctors and hospital administrators have to be persuaded to turn over their clinics, operating rooms, and post-op recovery areas to these strangers for a week, and accept the disruptions to their own work schedules. The scouts and team members try their best to be polite, since one arrogant comment can neutralize hundreds of hours of diplomatic effort.

The local physicians and officials appreciate the help, but sometimes seem embarrassed that they aren't able to take care of their own people from their own resources. Further, the group purposely seeks out the children of Indians and others who live at the margins of their society. And like the United States, Mexico has a long tradition of maltreating its native population.

The second lesson is the benefit of giving to the giver. The doctors leave their practices and pay their own expenses. The nurses give up vacation time to make the trips. Nevertheless there are plenty of volunteers for M.O.S.T. The limiting factor is usually how many operating tables the local hospital will commit. Some of the local citizens had difficulty believing that the group had no ulterior motive, wasn't seeking to convert anyone, and expected nothing in return. One doctor took an American colleague aside and asked him how much the U.S. government was subsidizing the team. "Nada," was the response.

The third lesson is the display of endurance and trust. A sixteen-year- old girl was burned on her face and arms saving her little brother when their house caught fire. After eleven surgical procedures, her left hand was a contracted claw, which the M.O.S.T. team straightened and released. Though the lower half of her face was rough with leathery scars, she was a beautiful young woman whose trusting vulnerability endeared her to all who cared for her. Her brother clung to her leg, cried when he saw the intravenous line inserted, and followed her to the vestibule of the operating room until the nurses restrained him.

Another teen-ager who had previously undergone reconstruction of a cleft lip and palate came to have his nose reduced. When such deformities have been repaired, the nose itself is commonly left broad and flat like a pig's snout, requiring later revision. As he was climbing on the operating table he gave rosaries to the surgeon, scrub nurse, and anesthesiologist. Since many of the staff aren't Catholic, as soon as he went to sleep a theological discussion began about the efficacy of the beads, but there was no debate about his motivation-and all appreciated the gifts.

The Indians' trust is earned slowly. Many of these children have such severe deformities that they have been hidden even from neighbors. Years of gradually accumulated successes were needed before parents would begin to trust their children to the strangers. Local priests have contributed in this regard by persuading the understandably suspicious Indians to let M.O.S.T. work on their children.

Much of M.O.S.T.'s success relates to the fact that the staff is made up of "pros": senior surgeons with skill and judgment, competent nurses ministering to sick children, and energetic support staff who get the job done without being asked. Some institutions have seen similar efforts founder because they have tried to operate with less than their first team. Further, local authorities resent their citizens being used for training American doctors, and so M.O.S.T. has avoided the temptation to use the outreach surgical team for teaching purposes.

Some of the problems are too complicated to be repaired locally, and so an annual "Mercy Day" is held in San Diego in late September. For this, Rotarians fly the children and parents to San Diego, and hospital staff devote a Saturday to mending their disfigurements. Marines from Camp Pendleton bring in cots and take care of the patients and families in the parish hall of Saint John's Church, two miles from the hospital.

There are some disappointments. One little boy had bilateral cleft lips and palate with carious upper teeth growing forward from his gums. His lower jaw was underdeveloped which made him look like a rodent. He was choking on food and was underweight. Attempts had been made to repair the defects several times previously and he came to M.O.S.T. for one last try. The plastic surgeon closed the hole in his palate but had to tell his mother that the chances of its holding were very low and the problems would likely persist. We all knew the boy probably wouldn't survive much longer.

The most difficult times for the team, however, come on the first day, when clinics are held to select the cases. For every three patients accepted, one has to be turned away, not because the problem is too severe to tackle, but because there is a limit to the number of cases that can be done in a week. To see the imploring looks on the parents' faces and to see the deformities left untreated breaks one's heart. As I write this story I am visualizing the disappointment on the face of a father who brought his son to the screening clinic. The youngster had a severe burn scar that had fused his upper arm to his chest wall so that he had no motion of the shoulder or elbow. There was no room on the schedule and we could only invite him to return the next time the team comes to Uruapan. But since M.O.S.T. goes to so many towns, it may be several years before that happens.

M.O.S.T. is a small group and has only a tiny effect in a country as populous as Mexico, but its efforts have improved life for the several thousand children operated on over the last ten years and have enriched the souls of team members nearly as much. The comments of one young girl summarized the overall impact of the team. She had undergone repair of disfiguring facial burn scars on an earlier trip and was returning for a final revision. She told the nurse in pre-op that previously she would hide inside her house. These days she enjoys traveling around the countryside, because, in her own words, "now, I am beautiful."