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."
"The whole idea of valuing the patient is crucial to the training," Brown told me. "Without that change of heart, the temptations are just too great, for power, for prestige, for money. It's everything they've seen modeled. They're well trained now, and they can go push people around, so it energizes me when I see that, with nobody looking, they do the right thing."
One evening near the end of my stay at Mbingo, I asked Brown how he had come to PAACS. Brown told me that he had done a number of short mission trips over the years, to Honduras, Armenia, and Ecuador, among other places. "I love having all the consultations and the scans and the labs they have at home," Brown said. "I'm still always thinking about who I can refer things to. But I think there's something about me that needs to be out on that edge to really trust God." A trip to Cameroon, he said, played a decisive role in bringing him to work as a missionary full-time. "I loved those short-term trips, and I was always thinking about the next one," he said. "But it was always really about us. You'd do 50, maybe 100 surgeries, but nothing would really change."
In 2003, he went to Meskine, in the far north of the Cameroon, not far from the Sahara. The hospital lacked a surgeon, and as news of Brown's arrival spread, the hospital was inundated by those in need of care. He described having to choose between patients to operate on, knowing the ones he delayed would likely die. "I nearly operated myself to death, for two and a half weeks I didn't stop," he said. While there, he found a young man, named Sadjo, at his hip. "He was there with me for every surgery. I mean every one," Brown recalled. Sadjo had gone to medical school for a year but then left for financial reasons, Brown believes. Brown recalled a surgery to remove a goiter from the neck of a twenty-five year old woman. It should have been done under general anesthesia, with the patient intubated, but a local missionary doctor convinced him it could be done with only Ketamine. The woman stopped breathing during the procedure. "It's one of these times when that voice in your head says, 'You fool, who told you you could do that?" Brown said. "I asked God to save her." He broke scrub, and tried to get an intubation tube into her trachea. He failed. "Sadjo got the tube in her," Brown said, shaking his head, still in disbelief.
Brown returned to the hospital later that evening and saw the woman there, nursing a child. "I was wasted, totally wasted," he recalled. "I had lost that lady. She died in my arms. And there she is, breastfeeding that baby. That's when I started reading about PAACS. A light went on in me, and I thought, maybe this is the way. If only this man, Sadjo, if only he could have the opportunity."
In January, David Thompson, the founder of PAACS, will begin learning Arabic. He hopes to open a PAACS program in Egypt the following year. His organization's budget climbed to $711,000 in 2012, after opening two new sites. They face a $130,000 shortfall.
In 2008, two of the preeminent figures in international health policy published a paper on surgical need in the developing world. Paul Farmer, who teaches at Harvard Medical School, and Jim Kim, who now runs the World Bank, wrote: "Although disease treatable by surgery remains a ranking killer of the world's poor, major financers of public health have shown that they do not regard surgical disease as a priority." In Africa, they wrote, "surgery can be thought of as the neglected stepchild of global public health."