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."
The devil in the room when discussing medical training is the problem of flight. Workers, after acquiring such a valuable skill set, rarely stay in the places that they are most needed. Ngoe Nesoah, a surgical resident at Mbingo who went to medical school in Nigeria, told me that nearly all of his classmate who trained in surgery have since left the country, many for Saudi Arabia. "Corruption has invaded the core leadership of Africa," he said. "And medicine is not unique." Nesoah is tall and keeps a thick mustache. He's well-read, and wears glasses with clear plastic rims and soccer flats with his scrubs. He grew up in both Cameroon and Nigeria, and has an outstanding serenity about him.
"My mother and father aren't happy that I'm here," he told me. "My mother thinks I should be, as a doctor, I should be driving a Benz car and living in a big flat," Nesoah said, his arms crossed over his surgical gown. "But it's not her weakness. It's a reflection of the society. If you ask an African, 'why you should go to medical school?' He says, 'I want to be rich, I want to send my children to England to study."
Medicins San Frontieres (MSF), in the last year, started a six-month obstetrics training program in Sierra Leone, geared toward training physician's assistants, rather than physicians. "Keeping doctors in the country with these skills has totally failed," Betty Raney, an OBGYN who recently returned from the program site, told me "When we train these chief health officers [the local term for physician's assistants], they can't leave and go to another country to practice because they wouldn't be sanctioned," she said. "So you capture them."
The project is unique for MSF, which is typically involved with emergency care, rather than development, and I asked Raney how she felt about the level of training the organization can confer with such a short course. "We have six months to teach them everything and anything we know about obstetrics, including cesarean sections, caesarean hysterectomies, vacuum, and forcep deliveries," Raney said. "We've graduated one guy, and he left with a really good set of skills," she said. "My OBGYN residency program is four years, so, yes, it makes you kind of nervous that you're sending these guys out with six months of training."
All 28 PAACS graduates remain working in underserved communities. "It's about that Christian heart," Jim Brown, the associate director of the Mbingo program, told me. "It's about choosing to live sacrificially and not moving somewhere where you can make a buck," Brown said, as we climbed one of the mountains that peer over Mbingo. "The Christian part of the name is non-negotiable. We could not do this without His strength. A lot of the time it's brutal down there."
I spoke with Bruce Steffes, the current executive director of PAACS, when I returned from Mbingo. "About three or four years ago we were trying to get a program in Ethiopia, and one of the government ministers was very much against this," Steffes told me, explaining that the minister's objection centered on the organization's unwillingness to accept non-Christian trainees. "He said, 'tell me what you're doing here.' And I said, 'the truth is that we've put out a number of graduates and they're all serving in rural Africa or in the cities where no one wants to work, and I'm willing to share everything I've got, from academics to teaching to testing. You can have them.' And I paused, and said, 'But it won't do any good.' I said, 'the only reason I can get these people going out in these rural areas and serve in places where they have trouble getting a decent education for their kids, not have all the amenities of a city, not get paid well, is because they're doing what they think Jesus wants them to do. Without that, it doesn't work. You can't convince other people to do this.'" The minister, Steffes said, removed the roadblocks impeding the program. "He just looked at me for a few seconds, and said, 'You're right,' and he finished the conversation."
I met Jim Brown at the Mbingo church the morning after my arrival. Practicing surgery in rural Africa comes with mind-numbing frustrations, and Brown, at times, seems a man atop a wire. The choir was moving past us as Brown introduced himself and his wife, Carolyn, a wound specialist, and I noticed the corners of his mouth pull down ever so slightly as he finished. A smile, it seemed, remained tucked between them. The look, which I would come to know well, is the face Brown makes when words fall short. The expression, without a decibel beneath it, says, 'If you could only know.'