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).
The chief resident at the hospital, Dr. Jerry Fahnloe Brown, grew up in the slums of Monrovia, the capital of Liberia. "I knew, from very young, that I wanted to do something about all that I saw," he told me one day outside the OR. Fahnloe has a thin mustache, and he speaks with a soft, confident cadence. A wide smile sometimes usurps his face when he pauses for emphasis. "And so my thought was to study business, and then" -- the smile grew -- "one day, to become the president of Liberia." Brown let loose with laugh at the admission, and fell onto the low shoulder of another resident standing with us, a Congolese named Degaulle. "You see, again you are talking to a politician," Degaulle said. "You came to find doctors and all you found was politicians."
It took Fahnloe eight years rather than the expected five to finish medical school on account of the Liberian Civil War. In 2004, wounded soldiers began packing the hospital. "One of the soldiers was not happy with how a nurse was taking care of his wound, and he slapped the nurse," Fahnloe remembered, his eyes wide and his chin slightly bowed as he looked me in the eye. "A doctor came over, to speak with the man. The soldier pushed his head through a window." Fahnloe's eyes grew wider. He explained that the attending physicians refused to treat the soldiers after the incident, and that many physicians subsequently fled the country, forcing the hospital to shut down. "The minister of health at the time was the only surgeon in Liberia. And he was teaching anatomy, so he had a very strong influence over the medical students," Fahnloe said. The sitting president, "through this minister, appealed to us to keep the hospital open. So we, the medical students, took over the hospital." At the time, Fahnloe had just advanced to his third year. He was a student on a pediatric rotation, and he instantly became the head of pediatrics.
After the war ended, Fahnloe began working at a government hospital. He was the only physician at the site, and was forced, like general practitioners across the continent, to practice surgery without any formal training. He recalled performing an operation to repair a ruptured spleen, with a friend trained in surgery in South Africa guiding him by phone, and his first colostomy, which he performed on his own newborn daughter. "She was born with an imperforated anus, and no one in the country could repair it," he said. She had a rectovestibular fistula, allowing some feces to drain through her vagina, but when she was two weeks old, she became septic, and Fahnloe knew he had to act. "I had looked in the book, to see what I could figure out," he said.
The colostomy was a success, and Fahnloe's daughter eventually had the condition repaired by a group in Michigan, but the brush, coupled with the death of a coworker, had a deep effect on Fahnloe. "I knew he was bleeding somewhere in his head, but I felt I was not capable of doing it, of operating on him. So we resuscitated him and put him in an ambulance for the capital." He got a call hours later saying that the coworker died on the drive. The incidents convinced Fahnloe that he needed to find further training, although the options were severely limited. A missionary surgeon at a hospital where Fahnloe had volunteered caught wind of PAACS, and recommended him. This summer, when Fahnloe graduates from PAACS and returns to Monrovia, he will be the fourth surgeon in the country.
The U.S. government spends around $8 billion on medically related foreign aid each year, roughly a sixth of the total foreign operations budget. The lion's share of the funds, which total to more than $50 billion, go to the governments of Pakistan, Afghanistan, Egypt, and Israel as economic and military assistance.
"You hate to use the term bang for the buck," Thomas Crabtree, a reconstructive surgeon based in Hawaii, told me, "but, very often, there's at least a chance for a very high level of efficiency when you're doing this type of work." Crabtree went to Stanford Medical School and trained in plastic surgery at the Walter Reed Army Medical Center. He spent 20 years in the military, and now serves as a senior medical advisor to the Pacific Command. In 2007, Crabtree was given a military volunteer award from the American College of Surgeons for his humanitarian work. In his acceptance speech, he recounted repairing a young Iraqi boy's cleft lip in a small town South of Baghdad favored by insurgents for ambushes and IED attacks. The boy came back a few days after the surgery ensconced by a small group, Crabtree told the audience. "This entourage," Crabtree said, "included an elderly man of regal bearing who identified himself as the local sheik and grandfather to the child. He said he understood there had been some problems on the road in the past. He said those problems have ended. They did. Countless millions of dollars and more importantly dozens of lives were saved because of a grandfather's gratitude."
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.'
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."
"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."