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International Medical Education: Do we have a responsibility to help?

by James Smith, MD, FACS
Today's Christian Doctor - Summer 2011

Have you ever thought what it would be like to have recently been married at the age of sixteen, and to now be expecting your first baby, not with joy, but with fear and trepidation? Why the latter? In Sub-Saharan Africa, residents don’t know that they have a 5% chance of needing a Cesarean section, or that they have a 5% chance of actually receiving that life-saving procedure. All they know is that they had friends in their village die in childbirth.

Such are the realties of available healthcare in much of the developing world, but nowhere are healthcare needs as desperate as in Sub-Saharan Africa. They have 11% of the world’s population, 24% of the global burden of disease, but only 2-3% of the world’s healthcare workers. In the field of surgery, 30% of the world’s population receives 75% of the world’s surgical procedures, but the poorer 1/3 receives only 3.5% of all surgical procedures. In Table 1, you can see the ratio of surgeons per population. To bring the numbers into perspective, the population of the US from the Mississippi River to the west coast, leaving out California, is about seventy-five million. Imagine that there are 120 surgeons for all of this population, but more than 100 of them live in Denver, and they only cater to the wealthy and prominent members of society. If you are poor and live in rural North Dakota, what are your chances of receiving even lifesaving emergency care?

So much for the need. You may be asking, don’t they have medical schools and train other healthcare workers such as pharmacists, nurses, and so on? They do, but there is that little problem, “the brain drain.” Zambia retained less than 10% of the doctors it trained from 1978 to 1999. A recent survey of Nigerian medical students showed that greater than 60% plan to emigrate. You may be thinking, why can’t they stay and help their own people, rather than leaving for greener pastures in an affluent country? I think the reason can be summed up in one word, OPPORTUNITY! The best students who do stay often choose public health or infectious disease as the best careers. Why? In those two fields, you have the best chance to land a job with an NGO or WHO. These two groups pay two to four times as much as government hospitals, and you have the possibility of being transferred to a developed country. Before we are too critical of their choices, we must ask what we would do if we made less than $1,000 a month, had to worry about our personal safety or that of our family, lacked basic medicines and were short on surgical supplies if we had any at all, and were then approached by a recruiter from a developed country with an opportunity that would solve all of those problems. Would you and I stay? Of course not.

The reasons are myriad. It is easy for us to blame and point to corrupt governments, the billions of dollars of aid poured into these countries over the last fifty years, a wrong worldview, or a poor work ethic. We could say it is their own fault or that the statistics I have presented are too overwhelming to even try to help. But then there are those multiple admonitions in both the Old and New Testaments in which God tells us over and over again to help the widow, the orphan, the poor, and the stranger in the land, all of whom have no protector. So can we make a difference?

I am convinced that medical education and training can make a difference, not just in medical knowledge, but in modeling how to treat patients on both a spiritual and personal level. I would like to highlight two missionaries who have used medical education to advance the Kingdom of God.

My first hero is Jim Jewell. In his mid 50s, he and his wife, Ellie, left a busy general/thoracic surgery practice to go to a small mission hospital in Western Zambia. After eight years, he was ready to return to the US for a well-deserved retirement, but was asked to join the surgical department at the University of Zambia School of Medicine. Not only has he had more opportunity to practice his surgical skills, but he has been able to influence a whole generation of young doctors spiritually and professionally. Every other year, when the CMDE conference for missionary doctors is going to be in Kenya, Jim says Ellie gets busy on her computer to raise funds for four to eight Zambian residents to attend the conference. One year, after nearly two weeks of being associated with missionary doctors and hearing daily teaching from the spiritual speaker, one of the residents accepted the Lord. I still remember the joy on Jim’s face when he told how this resident was asked to present what he had learned at the conference to the surgical department and ended his talk with a clear presentation of how he came to know the Lord. Yes, we can make a difference.

My second hero is David Thompson and his wife, Becky, who have been missionaries in Gabon for nearly thirty years. Becky has been training nurses from the beginning of their time at Bongolo Hospital. After about fifteen years of being the only surgeon, David looked at himself in the mirror one morning and said, “Who is going to do this when I am gone?” He realized that if he identified a Gabonese doctor and helped him get surgical training in the US, there was probably a greater than 90% chance he would not return. Out of this was born a vision to start surgical training programs in mission hospitals around Africa. Not only would there be a strong emphasis on academic surgical training, but they would also focus on building those surgeons up spiritually so they could be leaders in presenting the Gospel to the patients in their hospitals.

At the 1996 CMDE conference in Kenya, David presented his vision to the surgeons attending the conference, and out of this was born the Pan African Academy of Christian Surgeons (PAACS). Though the program began with one resident in 1997, it has expanded to graduate more than nineteen fully trained surgeons, with thirty-five residents presently in five hospitals across Africa (one in Bangladesh) and a goal to train 100 surgeons by 2020. A major goal is not only to train them to be competent surgeons, but also to help them in their walk with the Lord so they can witness to patients and colleagues. All of the residents agree to work in a mission hospital for five years, the goal being to see them have a heart to serve in rural hospitals where the needs are the greatest. It has not been easy for those finishing. Some have gone to bankrupt hospitals, but have been able to bring the hospitals back to solvency by attracting patients with their surgical skills. Some have been in war areas and have had to be evacuated. Some are isolated with no colleagues to share with and a lack of supplies, but they have cheerfully been willing to serve the Lord in this way.

These are just two examples of the potential for long-term impact on a generation of physicians. Not only can one do the traditional model of treating patients one by one, but you can multiply your hands and leave something behind by training young doctors. I think Jesus left us that example by reaching out to individuals, and also influencing the lives of eleven disciples who would be left behind to carry on His work after He was taken from them.

Recently, I saw a documentary about an organization known worldwide for its medical humanitarian work in the most dangerous and war-torn countries. The film followed four doctors in three different counties. Two things made a deep impression on me. First, when the doctors faced the loss of a patient because of advanced disease or lack of equipment and medication, their reaction was frustration, then anger, and finally resignation. To cope with the disappointments they would leave to party and drink. In contrast to the message of hope we have in the good news of eternal life, they had nothing to offer those whom they could not cure. Second, in one country, where they had a hospital for fourteen years during a civil war, the doctors decided it was time to leave when peace came. Even though the hospital was still a major provider for the poor in that area, it closed when they left. During their fourteen years at the hospital, they had not trained anyone to continue their work when they left. I think this example alone should motivate us to be involved with medical education and training.

By now I hope you are asking, “How can I help?” Many of you are already involved in short- or long-term mission work, but many say, “I can’t teach,” or, “I don’t like to teach.” Yes, teaching takes more time, fewer patients are seen, and we are not all gifted lecturers. However, as physicians, we are all teachers. We are all teaching every day by example, whether it is to our children or to those we work with. How many of you can think of a quiet, unassuming individual who has had an impact on your life? One can teach as a mentor in the clinic or at the bedside by sharing with students, residents, or established doctors how you would handle a medical problem in your practice. Sometimes, the little things make the most lasting impressions, such as speaking kindly to patients, treating them as people made in God’s image, sharing the Gospel, or doing even something as small as washing your hands between examining patients.

As we participate in missions, we can deliberately look for opportunities where we can teach those we are helping, especially with a servant’s attitude. We must be careful not to have a superior attitude that says, “Let me show you how you should be doing this.” The longer I am involved, I find that I have as much to learn from the people I am visiting as they have to learn from me.

There is nothing more rewarding than returning to a site and seeing some of the things you modeled being implemented. One example is in Kenya where Medical Education International teams were teaching a modified version of ACLS and ATLS in partnership with the Christian Medical Fellowship of Kenya. CMF-K has become a leader in developing training teams to several sites in their own country and are now poised to do this training in surrounding countries.

As I finish, my prayer is that I have stimulated you to think about how God can use you in medical education to advance His kingdom. Maybe you can’t be involved now, but you might make it a goal for the future or help support those who are doing this type of work. Education may not have the cachet of relief work after a major disaster, but the long-term effects will remain long after we are gone. I would leave you with this one verse, “to whom much is given, from him much will be required,” (Luke 12:48, NKJV). We have been given so much compared to the majority of the people in the world. Is it not time we gave something back?


James D. Smith, MD, FACS, is Professor Emeritus from Oregon Health & Science University of Portland, Oregon. He was visiting professor at the National University of Singapore from 1997 to 2011. He has had extensive teaching experience at several institutions in Africa and Asia. Dr. Smith joined CMDA in 1984 and immediately became part of the teaching faculty for the CMDE conference in Kenya. He has served on the CMDE Commission and is currently the Chair of the Medical Education International Advisory Council where he actively seeks new opportunities for MEI teaching teams to serve overseas. His passion is to use medical education as a mission field to serve the Lord. He also serves on the Board of the Pan African Academy of Christian Surgeons. He is the recipient of the 2011 CMDA Servant of Christ Award.