The chief resident at the hospital, Dr. Jerry Fahnloe Brown, grew up in the slums of Monrovia, the capital of Liberia. "I knew, from very young, that I wanted to do something about all that I saw," he told me one day outside the OR. Fahnloe has a thin mustache, and he speaks with a soft, confident cadence. A wide smile sometimes usurps his face when he pauses for emphasis. "And so my thought was to study business, and then" -- the smile grew -- "one day, to become the president of Liberia." Brown let loose with laugh at the admission, and fell onto the low shoulder of another resident standing with us, a Congolese named Degaulle. "You see, again you are talking to a politician," Degaulle said. "You came to find doctors and all you found was politicians."
It took Fahnloe eight years rather than the expected five to finish medical school on account of the Liberian Civil War. In 2004, wounded soldiers began packing the hospital. "One of the soldiers was not happy with how a nurse was taking care of his wound, and he slapped the nurse," Fahnloe remembered, his eyes wide and his chin slightly bowed as he looked me in the eye. "A doctor came over, to speak with the man. The soldier pushed his head through a window." Fahnloe's eyes grew wider. He explained that the attending physicians refused to treat the soldiers after the incident, and that many physicians subsequently fled the country, forcing the hospital to shut down. "The minister of health at the time was the only surgeon in Liberia. And he was teaching anatomy, so he had a very strong influence over the medical students," Fahnloe said. The sitting president, "through this minister, appealed to us to keep the hospital open. So we, the medical students, took over the hospital." At the time, Fahnloe had just advanced to his third year. He was a student on a pediatric rotation, and he instantly became the head of pediatrics.
After the war ended, Fahnloe began working at a government hospital. He was the only physician at the site, and was forced, like general practitioners across the continent, to practice surgery without any formal training. He recalled performing an operation to repair a ruptured spleen, with a friend trained in surgery in South Africa guiding him by phone, and his first colostomy, which he performed on his own newborn daughter. "She was born with an imperforated anus, and no one in the country could repair it," he said. She had a rectovestibular fistula, allowing some feces to drain through her vagina, but when she was two weeks old, she became septic, and Fahnloe knew he had to act. "I had looked in the book, to see what I could figure out," he said.
The colostomy was a success, and Fahnloe's daughter eventually had the condition repaired by a group in Michigan, but the brush, coupled with the death of a coworker, had a deep effect on Fahnloe. "I knew he was bleeding somewhere in his head, but I felt I was not capable of doing it, of operating on him. So we resuscitated him and put him in an ambulance for the capital." He got a call hours later saying that the coworker died on the drive. The incidents convinced Fahnloe that he needed to find further training, although the options were severely limited. A missionary surgeon at a hospital where Fahnloe had volunteered caught wind of PAACS, and recommended him. This summer, when Fahnloe graduates from PAACS and returns to Monrovia, he will be the fourth surgeon in the country.
The U.S. government spends around $8 billion on medically related foreign aid each year, roughly a sixth of the total foreign operations budget. The lion's share of the funds, which total to more than $50 billion, go to the governments of Pakistan, Afghanistan, Egypt, and Israel as economic and military assistance.
"You hate to use the term bang for the buck," Thomas Crabtree, a reconstructive surgeon based in Hawaii, told me, "but, very often, there's at least a chance for a very high level of efficiency when you're doing this type of work." Crabtree went to Stanford Medical School and trained in plastic surgery at the Walter Reed Army Medical Center. He spent 20 years in the military, and now serves as a senior medical advisor to the Pacific Command. In 2007, Crabtree was given a military volunteer award from the American College of Surgeons for his humanitarian work. In his acceptance speech, he recounted repairing a young Iraqi boy's cleft lip in a small town South of Baghdad favored by insurgents for ambushes and IED attacks. The boy came back a few days after the surgery ensconced by a small group, Crabtree told the audience. "This entourage," Crabtree said, "included an elderly man of regal bearing who identified himself as the local sheik and grandfather to the child. He said he understood there had been some problems on the road in the past. He said those problems have ended. They did. Countless millions of dollars and more importantly dozens of lives were saved because of a grandfather's gratitude."
Crabtree, although an advocate for the type of medical diplomacy he described at the conference, has strong critiques of the way medicine has been woven into US foreign policy so far. "In the past they've done two things that I think are wrong," he told me, speaking of the Department of Defense. "They do these, one week in, everybody takes some pictures, everybody's shiny happy and go home." Crabtree's second criticism concerns infrastructure. "We give stuff," he said. "Bar none, far and away, the biggest mistake we make is not supporting health care workforce development. You can buy drugs, you can put in laboratories, you can build clinics, you can do all sorts of things, but it isn't going to matter in the long term unless you have the people to put hands on people and either do the medical or surgical interventions."
Of the foreign aid dollars spent by the State Department on global health last year, nearly half went to the purchase of antiretroviral drugs for those suffering from HIV/AIDS. The State Department and PEPFAR (the President's Emergency Plan For AIDS Relief) provide financial assistance for training through a dizzying array of channels. The U.S. Agency for International Development (USAID), the primary vehicle for State's foreign assistance programs, couldn't produce a figure for total dollars spent training foreign healthcare professionals in recent years for me, let alone a figure for surgical programs. In the last two years, the Office of the Global AIDS Coordinator (OGAC) has also rolled out $130 million in training related grants intended to reach beyond HIV/AIDS treatment toward bolstering health systems. The grants -- most of which range between $500,000 and $1 million over five years -- pair U.S. medical schools with African counterparts and tackle a broad range of issues. Surgery is notably scant in grant descriptions, and where it does appear, it seems like an addendum.
Crabtree, who spent several years running the Department of Defense's dispersal of PEPFAR funds in Asia, suggested that the training of resident workforces to administer the program has largely been a successful endeavor. He questioned, though, the overall scope of the training initiatives the donor community has undertaken. "Everybody talks about how a development project has to be sustainable. Well, unless you're committed to generations of continually training people, you have to, on the front end, put in the resources for laying the groundwork for building a resident workforce population that can both deliver and train down the road," Crabtree told me. "We don't do that."