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."
When I asked Brown about the problem, he noted that the hospital staff is poorly paid. Most of the employees make between $100 and $300 per month, meaning nearly all of them must rely on farming or other sources of income to support their families. "They're not professionals. They're there for a job," Bruce Steffes, the PAACS executive director, told me when I asked about the problem and the extent to which other PAACS hospitals face the same frustration. "The professional mentality that you and I talk about is a luxury that exists only if you have enough money to allow people to dedicate themselves to certain things and certain principles. Why are they working there? Because it's the only guaranteed income that they can get in an area where otherwise they're going to have to go out and raise yams and sell them at the market. Many of them may have a third or sixth grade education at best, and they don't understand the pathophysiology of disease and the consequences of doing something or not doing something."
"I have to stay focused on them, and training them well," Brown said, referring to his ten residents. "There's a million and one things I can get distracted by, and destroyed by, but if I stay focused on them and their training, on training safe, competent, good hearted surgeons, that's how I can deal with everything else."
Brown made several short videos of his residents last summer, and he showed them to me on his laptop one evening. They're flip cam-styled interviews, with Brown asking questions in the kind of jovial tone of someone who's unsure why he's holding a camera. In one, a fourth year resident with light skin and a wide, handsome face describes the fear he felt when receiving calls from the OR before his training at PAACS. "When I used to get called to the OR I would tremble. I knew I was not competent to do the cases," he said. In another, Brown asks Ben Malikidogo, a first year resident from the Congo, why he chose PAACS. Malikodogo grew up speaking French and studied medicine in French, and still must work very hard to put his words in English. Malikodogo looks, for a moment, as if some sort of trick or time bomb has been lobbed in his direction. "I didn't choose PAACS, " he finally says. "I didn't have an option of choosing anywhere else." Brown moves on, and asks how his training compares with what he experienced in the Congo. "It's very different from the academic way we've known," he says. "We are trained in this spiritual way. We can share what we have in our hearts without any fear."