Saturday, September 30, 2023
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Sending Surgeons, Creating Surgeons

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.


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.


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)

Community Health Workers

Community Health Workers (CHW), also known throughout the state of Texas as Promotor(as), have been around for decades, and the value they bring to diverse programs has been documented extensively. Some community health workers are men, but most are women who are typically well-known leaders in their communities. Historically, they began as a volunteer workforce mostly for public health and non-profit organizations, disseminating education and resources throughout colonias along the border and other impoverished neighborhoods.

Just as health care has evolved, the same is true of the CHW para-profession. The breadth of the job functions and duties CHWs are capable of performing has also expanded. The trend has also shifted from volunteerism to full-time paid employment for CHWs. This shift began in 1999 when Texas became the first state to recognize CHW contributions and, through House Bill 1864, established a temporary committee that could make recommendations towards the training and certification of community health workers.
Since 1999, the CHW movement has grown beyond expectations. According to the 2015 annual report prepared by the Department of State Health Services’ Promotor(a) or Community Health Worker Training and Certification Advisory Committee, the number of certified CHWs has grown exponentially from 573 (2008) to 3,628 (2015). A total of 1,150 were trained or grandfathered into the program in 2015 alone.

So how many CHWs are entering the health care workforce? Texas data is not available to answer this question, but the Department of Labor has national data reporting industries with the highest levels of CHW employment include outpatient care centers, general medical and surgical hospitals, and physician offices. Texas is also listed as one of the states with the largest CHW populations, and the Texas labor market projects that the field will grow by 26% from 2010 to 2022.

Educational backgrounds for CHWs varies, ranging from on-the-job training to bachelor prepared workers. Some states, like Texas, have a mandated certification/training process. CHWs are prepared to work in health care through program specific modules geared towards identified disease processes such as hypertension, diabetes and asthma. Training CHWs to work as patient navigators and chronic disease managers is common in many health care facilities. CHWs also received motivational interviewing training along with different chronic disease management models.

One of the advantages of utilizing CHWs for health care teams is the cultural competency and humility they bring. CHWs also receive additional cultural competency, health literacy and interpersonal skill training. Natural attributes demonstrated by CHWs include being a leader in their communities. Outreach, education, recruitment and other abilities demonstrated by CHWs are characteristics of effective job functions that have made them valuable members of the health care workforce. CHW education revolves around the needs of the industry seeking to hire them. The value the health care industry is beginning to place on CHWs will propel the growth and synergy of institutions that train CHWs in order to maintain the marketability of the profession.

Fact or Fiction?

You’ll catch a cold if you go out in the cold weather unprotected. . . Cracking your knuckles will cause arthritis. . . Sexually transmitted diseases (STDs) can be contracted from toilet seats. . . Performing a biopsy or cutting into cancer can cause it to spread. . . Vaccines cause autism.

These statements have been proven false but there are people that still believe them to be facts. What constitutes a fact? Is it the source of the information? Is it the reputation of the individual relaying the information? Many myths are perpetuated simply because of where or how the information is obtained. After all, if some celebrity endorsed it, a family member said it, or if it’s on the internet, it has to be true, right?

With the evolution of technology, the days of reading a physical newspaper to get news and information are nearly nonexistent. People rely on the internet, and surprisingly social media, to inform them and ultimately shape their decisions and opinions. Because of this, it is imperative that research and the dissemination of the facts be emphasized. Those in academia have an obligation to provide communities with evidence-based information and it is important to know where and how people get their information, particularly related to health, so that it can be conveyed appropriately.

According to the Pew Research Center, statistics show that 90 percent of American adults now own a cell phone and 64 percent a smartphone. That’s an increase of almost 30 percent since 2011. What’s interesting is that of those who have smartphones, 10 percent rely on them, depending on their data plan, as their only source of internet access. This includes 15 percent of young adults (age 18-29), 13 percent of households with annual incomes of less than $30,000 and minorities (12 percent of African Americans and 13 percent of Hispanics). It was determined in 2014 that more than half (62 percent) of all smartphone owners use their device to look up information about a specific health condition. That is more than those that do online banking (57 percent). A person’s age and level of education followed by health and disability status are the most significant predictors of who uses the internet to seek out health information. With the many social media platforms out there, Facebook is at the top of the list when it comes to news and information. Around two-thirds (64 percent) of U.S. adults use the site, and about half of those users rely on it as their news source.

So what does all of this mean? We should know our audience and seek to inform them accordingly. The erroneous information will still be out there, so educating the public about reputable information sources is equally as important as providing accurate data.

Teenage Angst

I was one of those kids raised in a large school. My graduating class was more than 600 students. Nobody knew me and I did not have any close friends. School was a place that I went to at 8 am and left at 3 pm. Although it was a large school with a lot of students, I found myself isolated. The popular kids were the football players and the cheerleaders. I could not tell you the name of one person from my high school and there were over twenty five hundred. I was not connected to my school or my fellow students.

Fast forward a few decades and I have observed the school connection within the rural community. The rural community is a place where everyone knows you by your name or your family. There have been songs written about people in the town square, the church, local festivals, the local cafe, and in some cases the barbershop. However, it is remarkable that the central focus in the community is the school.

Small community schools provide a social connection for residents. They come together for sporting events, band concerts, school festivals, and special events. The school gym may be the largest indoor area for social gatherings in town. These activities offer opportunities for people to connect socially to the group.

At the end of the school year, the high school graduation is the central focus of a community. The graduating class may have fifteen to thirty students. The ceremony is supported by the community and is very personable. Some graduating ceremonies have a photo slideshow of each student from birth to the events of the senior year. They each have a connection to the other.

Adults that grew up rural in these schools have life connections as they grow older. The members in the community watch each other grow up, get married, have children, experience life troubles and blessings together. They are connected and their lives intertwine.

However, some of the adolescents never feel connected to the group and find themselves isolated for various reasons. As they struggle to find their place in the group, the feelings of loneliness, hopelessness and isolation become part of their belief system. They believe they are worthless and irrational thoughts begin to infiltrate their thinking. They have not developed or have not been taught appropriate coping skills.

Adolescents are impulsive, and without coping skills they may resort to behaviors that are detrimental to their safety and the safety of those around them. These dynamics have been identified as factors in school violence studies.

It is important to recognize students that are struggling with these feelings and intervene. Intervention can be as simple as listening to the students concerns, encouraging interaction with fellow students and a referral to a mental health professional.

School Connectedness

I’m being honest, I didn’t always hold a high opinion of “rural americans.” I was raised in the city, proud and privileged. I thought most rural folks were, well, backward. Over time, my feelings have changed. I would now characterize them as kind, wise, hardworking and community oriented. Why the shift in thinking? Education and work experience helped, but my understanding really changed when I immersed myself in the Ralls Independent School District.

Located on U.S. Highway 62/82 with a population around 1,915, Ralls, TX fits the rural community description to a T. Like other rural schools, Ralls ISD has the same needs and struggles as their urban and suburban counterparts. However, according to the Center on Innovation and Improvement, rural schools fair far better in achievement. This is certainly true in Ralls.

Our city schools are plagued with drugs, violence, high dropout rates and lonely and withdrawn students who fall through the cracks and may end up in our criminal justice system. Ralls ISD has a population of around 585 students, and 81.5 percent of these students are economically disadvantaged. This number is 15.6 percent higher than that of an urban school district not too far away.

Over half of Ralls ISD students are statistically at risk for dropping out. However, more than 96 percent of those students graduated in 2013.

In that same nearby urban school district, 42.6 percent of students are at risk for dropping out, with a graduation rate of 87.5 in 2013. Ralls dropout rate in 2013 was only 1.4 percent. Since then, they have had a 100 percent graduation rate. As the Center on Innovation and Improvement says, “Taking district socioeconomic status (SES) and per-student expenditures into account, the smaller the district, the higher the achievement.”
Lower volume places greater responsibility on a school to engender improvements. Rural schools rely on their available resources and are innovative. Strong relationships among staff, a team-oriented approach to planning, and disciplined work contribute to the high achievement of rural schools. Typically, teachers in rural school districts exhibit high concern for their students beyond the classroom and they also take an invested interest in their needs.

In addition, faculty relationships with families are strongly associated with achievement in rural schools. The school ties the community together in rural counties, and students perform better when they have a sense of belonging.


Alfred W. Adler (1870-1937) was an Austrian medical doctor, psychotherapist and founder of the school of Individual Psychology, a theory of personality. Adler focused his pioneering work on community life, prevention, and population health. Adlerian psychology stressed the importance of nurturing feelings of belonging, and he stressed the importance of community.

I’m an Adlerian counselor, and I use his theory as a way to understand and guide my clients. Collaborating and cooperating with one another can benefit society as a whole, instilling social interest and personal wellbeing.

Adler once said, “The goal of the human soul is conquest, perfection, security, superiority. Every child is faced with so many obstacles in life that no child grows up without striving for some form of significance”.

The Centers for Disease Control and Prevention says, “School Connectedness” is an important factor in both health and learning. School Connectedness is, in essence, the belief held by students that teachers, parents, and peers all care about their success, and more importantly about them as individuals. School Connectedness is a holistic approach to health and learning much like the ideas Alfred Adler espoused in the early 1900s.
As a Licensed Professional Counselor for The TWITR Project, I have had the opportunity to visit many different school districts throughout West Texas. Ralls ISD has been one of our TWITR school districts for the past three years. When I was asked to write a feature article, I immediately thought of Ralls. They are extremely invested in their students. There is always need in our rural communities, yes, but this is a rural community that has something to offer us, to teach us.

The “Wingspread Declaration on School Connectedness” describes three critical things a student must experience to feel connected:

  1. High academic expectations and rigor coupled with support for learning
  2. Positive adult /student relationships
  3. Physical and emotional safety

What does all that look like in real life? I think it looks a lot like Ralls ISD.

It’s not easy to describe the passion that the Ralls High School principal, Miguel Salazar, has for his students and teachers. Mr. Salazar is a terrific storyteller, and he graciously spent hours with me sharing the history of his district. He helped me understand what School Connectedness really is: it was already written all over the walls of the school in black and white photographs. Mr. Salazar celebrates his students and teachers by placing framed photos all over the school. He wrote a grant and was awarded funds to produce his picture project. If I can share what they know about school connectedness, then maybe we can contribute to the health of other students. So this is how they do it:


At Ralls ISD, expectations and support for learning begins with the administration. Principal Salazar stresses the use of technology in teaching his students. Each student is provided with a Chromebook to enhance learning opportunities. He also stresses the importance of having a relationship with students and says being able to build a rapport with them is a major factor in his hiring.

Shay Bolm, the school counselor, says Salazar really goes the extra mile in his concern for both students and faculty. She described encountering a suicidal student her first week at Ralls, and due to transportation issues, she personally drove the student to an inpatient facility to receive the necessary care. But the trip turned out to be longer than she had anticipated. In West Texas there are few residential treatment facilities for children, and the nearest major city to Ralls has none. She was worried, however, that there was no one available to pick up her own children. But Mr. Salazar picked her children up, took them home with him, and fed them. She says he is like this with everyone.

“He goes above and beyond,” Bolm said. “He is brilliant and sets high expectations for himself and others around him. He makes me want to be a better person. He makes our students want to be better. We have a lot of respect for him.”

Jeremy Griffith, the Ralls Middle School principal, has been with Ralls ISD for 13 years, and his wife also teaches at Ralls Elementary. In 2008, Mr. Griffith’s daughter Reese was born with a rare heart condition, Williams Syndrome. For several weeks, he stayed up at the hospital with his daughter. During this time, Mr. Griffith was the head football coach. He said his fellow coaches would bring video of the games up to the hospital so he could watch and help develop a plan for them. He says he will never forget all the love and support the people of Ralls provided his family.

I learned a lot about Reese while visiting Mr. Griffith and others in Ralls. Reese never met a stranger. She was a beautiful, empathetic little girl who cared deeply for others. And she loved to play softball. The Ralls ISD baseball field was named in honor of her. She was four years old when she passed.

Of course, Ralls is equally dedicated to academic achievement. Chelsey Campbell, the principal at Ralls Elementary School understands that in order for students to excel, parents must buy in. For the past three years, Mrs. Campbell has worked diligently on building strong connections with “her” parents. In addition to hosting an elaborate Fall Festival, countless music recitals, and a popular recycling program, each year the school hosts a book fair. The fair has become a huge community event, and parents do a lot of their Christmas shopping there because it allows families who struggle with transportation to shop for gifts without leaving town. The book fair also provides a way for the school to get books into more students’ homes, encouraging literacy and learning at an early age.
Ralls also has a great after-school program. The Edge Mentoring Program is designed to keep children off the streets and encourage academics and creative learning. A bus picks students up and transports them to the program where they are given help with homework and offered classes in the arts, cooking and baking, candy making(!), and most recently archery. The program is designed to offer the enrichment learning a student may not get in his or her home. The Edge Mentoring Program also gives parents extra time to get off work without leaving their children unattended.


One of the coolest stories shared with me about the students in Ralls was about a boy named Geronimo. He was a high school student with an enlarged heart that prevented him from playing sports. He loved his school and everyone loved him. He also loved NBA star Lebron James, so the Children’s Miracle Network sent Geronimo to watch Lebron play. During the unveiling, students performed a flash mob, dancing to the song “Geronimo.” He and his parents were unaware that the Children’s Miracle Network was about to give him such a great gift. Two days prior to the event, the entire school practiced the routine. The cheerleaders taught them the dance. It’s this sense of community and connection that makes opportunities like this possible.

Last year, for example, the Ralls Student Council decided to help other students in need. Student Council Representative Virginia Meza suggested a dodgeball tournament to help raise money to purchase winter coats for any student who needed one. With students helping to spread the word, the project was a success. Around 50 coats were provided to kids in the district.


In each of the principals’ offices, on their computer screens, is a live view of their campus. I was visiting with Mr. Salazar, clarifying a few stories, and I swear that man has eyes in the back of his head. We were not even looking at the computer when he jumped up and said, “Where is that student going?” He rushed out of the office to find out why the student left the building. School security is another big point of emphasis in Ralls ISD.

“Ralls ISD looked at several factors when we implemented access control on all buildings as well as the policy allowing certain employees to carry a firearm,” said Salazar. “Student and staff safety is a top priority at Ralls ISD. Based on the increasing number of shootings in gun free zones and recognizing the delay in response from emergency first responders, including law enforcement, in an emergency situation may have devastating consequences, the School Board adopted the policy allowing specific school employees to carry firearms.”
Ralls ISD also takes extra precautions when it comes to the mental and emotional well-being of their students. They know there are times a student needs extra help despite the best efforts of the school. Ralls asks for help and welcomes outside counselors and telemedicine.

As one staff member noted, “We are not perfect, and we don’t claim to be.” They are however, a team of caring educators who understand the struggles their students face because they know each of them personally.

Visiting Ralls ISD has been a humbling experience. Rural America has something to teach us all when it comes to education. They are connected, and it runs deep. Many of the students I spoke to said they appreciate the small classes and individual attention they receive in Ralls, but I think one student in particular summed it up best: “Our teachers tell us they care.”