A friend from South Africa once told me, “When you travel to a strange place, where you first arrive will always feel like home.” He had sensed that Kenya was a deeply personal place for me, like another home.

Since first visiting there in 1995, I have been privileged to return on several three-to-nine-month stints. So, while capacity building sounds sterile and dispassionate, it is in fact a very heartfelt topic for me. One is amazed how widespread poverty and its effects are across the low and middle income countries (LMIC), and yet how little resources it would take to have an enormous impact. All of us have the means to participate and create meaningful, durable change.

Tenwek Hospital is a sight to behold. To better understand the work being done there, let me take you to the setting. For those who have never been to Africa, it can be a difficult to imagine. Kenya is not the brown, desolate place often pictured by many Americans. Tenwek Hospital is on the rolling hills of the Kenyan Highlands at 6,700 feet at the edge of tropical rainforest.

Understanding the region also means grasping the size of Africa. The Mercator map projection we are accustomed to seeing in the classroom makes Kenya look deceivingly small. It is actually similar in size to Texas (Kenya: 225,000 square miles, Texas: 270,000). Both are highly populous, though Kenya has approximately 50 percent more people (Kenya: 47 million, Texas: 28 million). While predominantly Christian (83 percent), it has a large Muslim population (11 percent) that has been present for many generations along the coast and toward Somalia. As is typical of LMIC’s, Kenya is very heavily weighted toward younger ages. The GDP of Kenya is $142 billion (Texas $1.4 trillion). Kenya is the star of East Africa in terms of tourism, internet connectivity and cash crops like tea and coffee. It is also the regional hub for trade, an excellent environment to encourage capacity building.

In Bomet County, where the hospital is located, most homes are still made from mud, dung, and sticks with a traditional conically shaped thatch roof, though increasingly corrugated steel roofs are used. The area around Tenwek Hospital is probably best described as “densely populated rural.” Each farm, usually under a half acre, abuts another small farm. Tea dominates the agriculture in the area, and tea processing factories dot the horizon. Standing at one factory you can almost always see another one off in the distance.

Tenwek Hospital was first founded in 1937 by missionaries with World Gospel Mission and has since expanded into what we would recognize as a robust teaching hospital with a catchment area of around 600,000 people.

After the first doctor, Ernie Steury, arrived in 1959, rapid growth followed. An active community health program was started in 1983 followed by a nursing school in 1987. In the 1980’s, the nearby river was harnessed for hydroelectric energy which provided reliable electricity.

One decade later, the scope of the hospital changed dramatically with the addition of accredited training programs. General government internships were begun in 1995. Building on this, accredited residencies in general surgery (2007) and orthopedic surgery (2014) were added. With the addition of a computed tomography (CT) scanner in 2011 and electronic medical record (EMR) in 2013, Tenwek Hospital has radically transformed since 1937 into a 300 bed, modern hospital that rivals or surpasses the capabilities of national referral hospitals in many service lines.

For the visiting surgeon from a Western country, a quick visit to any other “typical” mission hospital in Africa is a reminder of how close to American medicine Tenwek Hospital is. It is easy to take for granted the fairly modern equipment, capability for high-level operative endoscopy, laparoscopy, readily available anesthesia, and a reliable supply of almost all basics for surgery.

But caring for a patient is about far more than attempting to provide the most advanced Western technology at affordable costs. And in fact, it is not the previously mentioned strengths of Tenwek Hospital compared to other hospitals that distinguishes it from other referral centers such as the national referral hospitals. It is set apart by its underlying vision: “Tenwek Hospital is a Christian community committed to excellence in compassionate healthcare, spiritual ministry, and training for service to the glory of God.” When the inevitable crises of any organization strike, it is this mission, obeying Christ’s command to “love your neighbor as yourself” that redirects and reenergizes their efforts.

PAACS: BUILDING AFRICAN CAPACITY

The statistics describing medical and surgical capacity in Africa are staggering. When counting the number of physicians per 1,000 population, the United States has 2.5 per 1,000. Kenya has 0.2. When it comes to surgeons, the United States has 65 per 100,000 population. Kenya has a mere 1.9 surgeons per 100,000. While this seems low, it is considerably higher than many other African nations (Ethiopia: 0.6, Tanzania: 0.3, South Sudan: 0.3). Pediatric surgeons are best measured per million population. There are 18 pediatric surgeons per million in the United States (England: 29, Germany: 23). Nigeria has a paltry 0.5 per million. Kenya likely has fewer than 0.2 per million population. Most practice in the capital city.

What can be done to build capacity? In 1996, a group of missionary surgeons in Africa met at a retreat and deliberated over what could be done to meet this desperate need for better trained physicians. This led to the foundation of the Pan-African Academy of Christian Surgeons (PAACS). Since the first graduate completed training in 2004, they have graduated over 67 surgeons serving in eighteen African nations. In addition to serving the least and the most impoverished, they are also involved in training the next generation. Several have returned as faculty and program directors.

In 2012, Brian Till described his firsthand experiences with PAACS in “The Atlantic.” Entitled “God’s Surgeons in Africa,” the words below the headline were telling: “A Christian organization is educating surgeons who stay around despite little pay or prestige — sometimes despite real danger.”

Within the vision of PAACS is this essential kernel of spiritual commitment that drives the surgical training. And so far, this has borne fruit with every graduate remaining on the continent. While this might seem like Western paternalism at its worst, it is instead a partnership. Trainees are carefully selected for their shared values and commitment to serve his or her people, no matter their socioeconomic status or desirability.

A DEEPER MOTIVATION

I often recall a particular conversation I had with one of my Tenwek Hospital colleagues, an internal medicine doctor. Through a gritted, tense smile he said, “You know, John, I’ve lost 965 patients on the adult medicine ward over the last two years.” He was smiling, but it was clear he was deeply distraught by the loss of human life.

How do you process this? It is not as easy as you might think. And this is where your sense of purpose is crucial. Is it about achieving fame and glory? We can easily agree that is not an acceptable rationale. But what about a seemingly more innocuous reason, and one I have heard discussed among surgical academicians: to hone one’s surgical skills? Not only is this questionable ethically, it does not encourage working with the least reached, the most impoverished or the most difficult to care for. Even love for our fellow man is not sufficient. Why? The endless hurt, unending disease, and the often-thankless hurting humans wear you out and burn you out. While this may seem pessimistic, it is not. It is a recognition of the need humans have for a deeper, spiritual meaning and motivation. It is a realistic evaluation of our capacity to continue serving others amid great challenge and adversity.

While a love of fellow humans is not sufficient, it is the essential motivation when it is grounded spiritually. God gives us the strength and the love for others that we cannot find in ourselves. We would do well to heed the encouragement of the Apostle Paul:

“Don’t just pretend to love others. Really love them. Hate what is wrong. Hold tightly to what is good. Love each other with genuine affection, and take delight in honoring each other. Never be lazy, but work hard and serve the Lord enthusiastically. Rejoice in our confident hope. Be patient in trouble, and keep on praying. When God’s people are in need, be ready to help them. Always be eager to practice hospitality.” (Rom. 12.9-13)

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John W. Fitzwater
John W. Fitzwater is Assistant Professor of Surgery in Pediatric Surgery at the Texas Tech University Health Sciences Center.

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