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.'
Surgical scissors are rarely sharp at Mbingo; there are no amputation knives; cheap suture needles, manufactured in China, bend straight against tough tissues; the nearest CT scan is three hours away by car. One night, as I walked home with Richard Yeager, a vascular surgeon from Portland, OR, I asked him about practicing at Mbingo. "One time I was doing a surgery with George, and Jerry came in and changed out our Bovie," a cauterizing instrument used to cut tissues and seal leaky blood vessels. "Except the one he left us with didn't work at all." Yeager looked at me with a smile. He works in the VA system, and served in Korea, and there's something kind and unshakable about him. "So we just went on. And I guess we didn't need it as much as we thought. You know the lights go out so often, and at first you really stop. But you get used to it, you know. Someone pulls out a flashlight and you keep going."
Most often, the surgeons at Mbingo -- both the visitors and PAACS residents -- seem more let down by human resources than physical ones. Orders to remove catheters and IV lines are routinely dropped. Lab work, even if urgent, won't be processed for days sometimes. Notations specifying drugs that should not be administered are disregarded. Most maddening, for the surgeons, is that the OR staff will rarely start non-emergent cases after three o'clock in the afternoon. "What frustrates me is we're training these guys at a standard that we can't then implement," Brown said. "I believe they really care about quality of care and medical education here," he said, speaking of the organization that runs the hospital, the Cameroon Baptist Convention. "But I don't know if they understand what it takes to do it well, and the only way I can help is by winning their trust. They've seen so many people come and go. And there's a cultural divide there."
On rounds one morning, Brown's frustrations boiled over. A patient, a young man with a condition known as myasthenia gravis, had missed a dose of an acetylcholine booster the night before. Without the drug, the man reverted to his symptoms, unable to lift his head or limbs. Several days before, his thymus had been removed to ameliorate the autoimmune disorder. There was a shortage of pills that he needed, meaning that the man needed subcutaneous shots every four hours until a physician traveling to Mbingo could bring more of the oral medication. "Everyday there are things that need to get done that don't happen," Brown said, standing alongside the man's bed. "We have a lot of people here that don't get what they need. We had two amputations yesterday that didn't get done because there wasn't blood," he continued, his voice rising. "There was blood. The lab is all too happy to tell you that there isn't -- I've talked to the head of the blood bank, I've talked to the admin, I don't know how to solve that. But if you need blood, you have to go down to the blood bank physically, yourself, and get it. It's there." Brown slowed. "When you operate on someone, you're committed to taking care of them, whatever it takes. If this man doesn't get his shot, everything we did over there was a waste," he said. "He has my phone number, and if he misses a dose, he knows he's supposed to call me."