In countries where many are performing surgery without any formal training, a Christian organization is educating surgeons who stay around despite little pay or prestige -- sometimes despite real danger.
In 1994, God told David Thompson to start training surgeons in Africa. Thompson was in the fifteenth year of a mission to Gabon at the time, in West Africa. "I just realized that I couldn't keep up with the demand," Thompson told me. "I was just operating night and day and I knew I was going to burn out. And I knew that when I burned out I was going to leave, and that everything would go back to the way it was before I arrived."
Thompson is tall. He wears a mustache, and has deep creases alongside his eyes and mouth. I asked him how God had spoken to him. "I had a habit of spending about an hour a day early in the morning reading the Bible and praying and meditating on it and listening to see what God said to me," he said. Thompson grew up at a mission in Cambodia, and while he was a senior in college, in Pittsburgh, both of his parents were killed amid the Tet Offensive in Vietnam, where they were serving as missionaries. "Often times, in those moments, when I would be saying, 'God what are you telling me?' I would just get a very clear thought in my mind: 'You need to do this, this is how you can solve this problem.'"
The need for surgeons in sub-Saharan Africa is so profound that it's genuinely difficult to comprehend. "I was born by C-section, and when I was two months old I had an emergency operation on my stomach. When I was 23, I had appendicitis," Adam Kushner, a lecturer at Columbia Medical School, told me. "Those are three relatively simple procedures. A lot of people that have problems like those in say, Sierra Leone, just die," he said. "I mean, can you imagine a kid falling out of a tree, and then being disabled for the rest of their life because they couldn't get their arm fracture fixed? It's insane." Kushner's organization, Surgeons OverSeas, estimates 56 million people are in need of surgical care on the continent -- twice the population suffering from HIV/AIDS.
In 2009, Kushner worked with the Ministry of Health in Sierra Leone on an audit of the country's surgical capacity. Sierra Leone has a population of six million, roughly the size of Los Angeles and Houston combined, and the study found nine surgeons practicing in the country. The World Health Organization (WHO) estimates that a health system needs one surgeon for every 20,000 citizens to meet the burden of disease. By that measure, Sierra Leone has a shortage of 291 surgeons.
The deficit is equally dire elsewhere in Africa. Kenya and Uganda, with two of the continent's strongest medical education systems, have 355 and 100 surgeons respectively, meeting 19 percent and 7.4 percent of need based on WHO projections. Rwanda has 35. "Every day I see things that just make me rage inside," Jim Brown, a missionary surgeon in Cameroon, told me.
The results of these deficits are often horrific, as surgical procedures that should be safe and routine -- appendectomies, caesarian sections, and amputations, for instance -- are carried out by general practitioners with little or no training, rather than surgeons. "Every week, almost every day, we have someone in here draining stool from an abdominal incision, or a ureter tied off, or the wrong operation done somewhere else," Brown said, standing atop a ward with 70 beds stretching in three directions. "And very often they die." Brown is slight, with an insufferably honest face and a subtle trace of southern to his locution.
"The ones that really get me are the ones that are told they had surgery -- they get anesthesia and incisions and they take their money, but they don't actually operate. They usually come up here after their third or fourth attempt somewhere else, and they've never had a fistulectomy, or a myomectomy, or whatever it is they need." At another hospital where Brown worked, prior to moving to Mbingo, he found that O.R. staff members were performing surgeries themselves after hours and on weekends.
"One of the biggest problems I see," Kushner told me, "is that ministries of health are hesitant to pursue surgical programs because the donors don't want it. The money is coming in and earmarked for certain programs. And even though you see a need for another type of program, you don't want to piss off your donors. There's this perception that surgery is expensive."
In 1994, David Thompson took the message he received -- to pivot from performing surgery to teaching it -- to a meeting of missionary surgeons in Brackenhurst, Kenya. The vision was to post a U.S. board-certified surgeon at a Christian hospital with reasonable capacity, and to augment the teaching by luring other surgeons, perhaps 10 or 15 each year, to visit the hospital for short-term teaching stints. Almost no one thought it could work.
Thompson took on his first resident in 1997, in Gabon, as a pilot program. "Within about five years I had enough help that I got my life back. And the other hospitals saw that it was working and it kind of starting spreading," Thompson said. The organization grew in fits and starts, some early programs going under while others managed to flourish. In 2011, Thompson's organization, the Pan African Academy of Christian Surgeons (PAACS), was training 43 residents at 10 hospitals across the continent. It has 28 graduates, all of whom remain in Africa, working for underserved populations. The organization's operating budget for 2011 was $550,000.
Mbingo Hospital is tucked high in a lush valley near Bamenda, a city of half a million in northwest Cameroon. It's the home of the largest residency run by PAACS, and Jim Brown, from South Carolina, is the program's associate director. The site was founded as a leprosy clinic in 1952, and became a hospital a decade later. Today, it's a sprawl of low yellow buildings with red metal roofs. The entire place looks like it was laid with perfect rolls of sod, millennia ago, and then left to grow wild.
On my first night at the hospital, I asked a visiting pediatric surgeon, Jacob Stephenson, who trained at UCSF and University of Washington, how the skill of the PAACS trainees compared to that of his residents at home in Virginia. "In terms of technical skills, I would say they're comparable, maybe even a little better," he said. "In other ways I'd say they're stronger." Overwhelmingly, the string of surgeons that visited Mbingo while I was there agreed with Stephenson's assessment, particularly on the strength of the residents' diagnostic skills and judgement. "They are very good at problem solving and making clinical decisions with much less technology to rely on," Stephenson said. "You can't just tick a box and order a CT scan. That means you have to get very good with other ways of assessing a patient."
The hospital at Mbingo has 270 beds and is staffed by 122 nurses and 26 physicians. It's one of four hospitals run by the Cameroon Baptist Convention. There are ten surgical residents at Mbingo: four from Cameroon, four from the Democratic Republic of Congo, and one each from Liberia and Uganda. They're taught from Schwartz's Principles of Surgery, sit for weekly tests and mortality and morbidity meetings, and take exams modeled on the American Board of Surgery Inservice Training Exams (ABSITE).