As the rainy season nears an end in Africa’s Rift Valley, the boys harvesting avocados start falling out of trees. If a boy breaks a bone, he may go to Kibuye Hope, a rural mission hospital in the East African nation of Burundi. There, for the first time in the 73-year history of the hospital, he may receive care from a full-time, permanent missionary surgeon who is Burundian.
That surgeon, Alliance Niyukuri, joined the missionary staff of Kibuye Hope in 2018, moving his family to its residences after he completed his medical training in Gabon. He is one of the first 100 graduates from the Pan-African Academy of Christian Surgeons (PAACS).
“I’m hoping that my presence here can encourage other Burundians and allow me to be a role model to students coming to the mission hospital,” Niyukuri said. “The Lord is [calling] more and more young graduates like me, calling us also to serve in the mission hospitals.”
Niyukuri is part of a long-hoped-for cohort of African missionary doctors serving in their native regions. It is the result of a larger shift in medical missions strategies that many organizations started making a few decades ago to train and empower Africans to practice medicine. The organizations recognized the potential of the Christians in Africa and sought new ways to deal with the continued shortage of doctors.
“The vision in the late 1990s was audacious,” said Mike Chupp, CEO of the Christian Medical & Dental Associations, a US professional group that sponsors overseas medical missions and partnered with Loma Linda University to start PAACS in 2003. “It was, by 2020, to graduate 100 general surgeons in Africa for Africa.”
This is no small undertaking. It costs PAACS $25,000 per year for five years to train a surgeon, according to executive director Susan Koshy. But by November 2019, the academy had graduated 92 surgeons—on target to meet its goal.
Missionary and charity groups large and small have launched programs to support African missionary doctors. MedSend, which works with 55 agencies, has started a National Scholars Program to sponsor medical training. Africa Mission Healthcare Foundation is working on plans for a network of teaching hospitals. Still more groups are sending short-term medical missionaries to train health care workers.
The trend seems to be at an inflection point, with the investment in African physicians making a difference in a number of nations and within mission organizations. Today, medical missions are more about investing in African doctors than sponsoring procedures.
Physician shortage
There is a chronic, urgent shortage of physicians in most of sub-Saharan Africa. Recent numbers are hard to come by, but in 2013 in Nigeria, Africa’s most populous country, there were fewer than 1,000 obstetricians to meet the needs of a population of 172 million people where the average woman has about five babies.
The worst physician shortage is probably in Malawi, a population of nearly 19 million, which had 284 physicians in 2016, according to the World Health Organization. The Democratic Republic of the Congo (DRC) has a population about the same size as Germany but only 1/50th the number of doctors.
The challenge is the “inverse care law,” a term The Lancet medical journal used in 1971 to describe the rule that the needier the place, the worse the health care options. A corollary is that the more privatized medical care is, the worse its availability for the poor. Mission hospitals have long stood in the breach.
These doctors treat dangerous diseases and common illnesses, like influenza and diarrhea, that can be deadly. They see pregnant women and respond to lots of accident victims. In Madagascar, PAACS graduate Marco Bien Aime Faraniko works at a mission hospital in the capital city. The majority of cases he sees are motorcycle accidents.
G. Randall Bond, dean at the Frank Ogden School of Medicine at Hope Africa University in Bujumbura, Burundi, said that’s not surprising. “The biggest killer in Africa for people who are not under five is trauma,” he explained. “Falling from trees, traffic accidents, bikes, etc.”
Having enough people to help can be a daily trial. Lazare Rukundwa Sebitereko, president of a Christian community university in rural DRC, says his community is badly in need of more and better medical care. There are only two doctors to serve the more than 70,000 people in Minembwe, in eastern DRC.
Responding to need
African needs led Western Christians to send doctors to the continent to treat patients in mission hospitals. In the late 20th century, the disadvantages of this model became more obvious. Missionary doctors would work under difficult circumstances, taking care of an enormous breadth and number of cases, until it was time for them to retire or leave.
“It was me serving a population of 50,000 people,” Bond recalls. “I just did what I could do; whatever I couldn’t do just didn’t get done.” There were never enough new doctors.
But last century’s mission hospitals aren’t finished yet. Kijabe Hospital in central Kenya is more than 100 years old and draws patients from the entire region. Now, it has developed into a teaching hospital. Likewise, Tenwek Hospital in western Kenya was founded by the World Gospel Mission in 1935. It started training Kenyan nurses in 1987, began a medical internship program in 1995, and established a general surgery residency program in 2007.
Increasingly, it seemed like training African physicians was a better way to meet the need. The new model of missions is more efficient, Bond said. In his current role of medical school dean, each of the physicians Bond trains becomes part of the solution.
Pete Halestrap, a doctor at Kijabe Hospital and a missionary with Africa Inland Mission, also thinks this is more practical. “To develop and mentor and disciple other people is probably the most valuable thing [missionary organizations] could do,” he said. “Far more than buying us another piece of equipment.”
Kijabe Hospital has been serving people in the entire region of central Kenya since it was founded by the Africa Inland Mission more than 100 years ago. It started offering postgraduate residencies in partnership with PAACS, and today half of the attending physicians are Kenyan.
Getting enough national doctors to staff mission hospitals isn’t easy, though. Africans who want to be doctors face big challenges and are asked to make a serious, life-altering commitment. If a doctor has a residency in the US, for example, there is a temptation to stay and make more money, which can be used to support families and communities back home.
“They make five or ten times the amount in another country and send it back to their families,” said Jason Fader, a surgeon at Kibuye Hope.
PAACS requires graduates to commit to at least five years of work in poor areas of Africa. Koshy said 100 percent have served that long; some more. “We have found that even beyond their five-year commitment, about 51 percent of them continue on in the underresourced areas,” she said. “On a long-term basis, it’s about 35 percent.”
Infrastructure and travel also can make things difficult. Faraniko said medical school applications can be stymied by such basic issues as a lack of internet connection. His first attempt at residency in Ethiopia was interrupted by visa trouble. He returned home, got married, and years later started a new residency in Gabon, with support from PAACS. He says his surgery specialization wouldn’t have been possible without PAACS.
Despite the challenges, African physicians have distinct advantages. In Kibuye, Niyukuri speaks Kirundi with his patients, while Fader has to work through a translator. “What I’ve seen with him is that he’s able to very quickly establish trust,” Fader said.
Others have seen similar things. At Kijabe Hospital, Halestrap recalls a village chief whose two children were treated by Kenyans. The chief was moved to a new level of trust.
“When it came time to go home,” Halestrap said, “the chief was so struck by the care and the love he’d received in the hospital that he then said to the missionaries who’d sent them all down, ‘You’re now welcome, you can show the Jesus film, you can do what you like.’ ”
Advocates of this new model also hope there will be more changes in the future. Sebitereko wants medical missions to be more collaborative. “It cannot only be in terms of [expats] coming and giving services, but also coming and learning,” he said.
He hopes to see a new era of respect, as well as investment. And missionary doctors elsewhere—African and otherwise—agree.
Focus on Mission
This idea of turning mission hospitals over to local leaders is not new. But it is newly successful. There are multiple examples of mission hospitals that tried to turn over operations and patient care, but, as Bond puts it, the hospitals would “dwindle away and collapse.”
Chupp says this is because the missions organizations shifted their resources and attention from the hospitals. The new staff and administration often changed the way they conducted their practices in order to earn enough. Advocates of the newer, slower model of training and long-term investment hope that support from PAACS and other missions organizations will prevent that.
Financing can always raise issues, though. “One of the big challenges,” Halestrap said, is “how to pay your staff appropriately and also fit the mission and vision of serving the poor.”
There are also political pressures on mission hospitals, which can impact Africans in ways that they wouldn’t affect foreigners. And incentives for hospital earnings are frequently misaligned with desperately needed preventative care and public health initiatives.
Halestrap says, “The only way of combating that is to make sure that your key leadership and senior medical and nursing staff have got that mission and that vision.”
Susan Mettes is a researcher and writer living in Washington, DC. She lived in Burundi for two years.
