Combating disease and brain drain

A 2 a.m. phone call awoke Dr. Juvenal Musavuli at his house. An obstetrics patient needed surgery.

“Give me two minutes,” Musavuli said.

Musavuli lived within walking distance of the hospital, where he could hear the Atlantic Ocean’s waves crash against the West African shore. But nighttime in Monrovia is sufficiently dangerous that doctors responding to calls drive to the hospital or have hospital security guards come pick them up.

In five minutes, he was at the hospital. When Musavuli saw the patient in distress, he decided she didn’t need surgery and put her on other treatment—he doesn’t want to do surgery when it’s unnecessary. In the following 24 hours he had plenty of bloody surgical work: He fixed an amputation on a child so the child could use a prosthesis. He performed a modified radical mastectomy on a woman with breast cancer in a country that has little other cancer treatment. He dug out and removed an apple-sized cyst from deep inside a woman’s neck, closing with the wrong size suture because that’s what he had.

This was late 2019, and Musavuli was one of two general surgeons at Eternal Love Winning Africa (ELWA) Hospital in Monrovia, Liberia. Faith-based hospitals like ELWA, a 57-year-old institution from Serving in Mission, formerly Sudan Interior Mission, have remained reliable places for medical services through crises like Ebola and the coronavirus pandemic.

But something is remarkable about the operating room at ELWA, a hospital that was on the front lines of the Ebola crisis: The surgeons, nurses, and technicians were all African, a feat that took years of training and investment.

And ELWA is a teaching hospital, so young Liberian residents and interns watched Musavuli as he worked and taught. While he used the less-than-ideal sutures, he taught an intern how to stitch.

Musavuli’s residency was in a hospital near the Sahara, and he knew the value of interns learning to adapt to missing supplies or limited diagnostics amid a high volume of cases. As a teacher, he shows a kindness to those working for him that is not always characteristic of surgeons with heavy caseloads.

The ELWA operating room team often does about 10 surgeries a day. On these kinds of days that start at 2 a.m., Musavuli drinks coffee rather than his usual tea. “Next case!” he called out from the operating table.

“If we invest in the African surgeon, yeah, some will still go outside, but maybe 70 percent will remain in Africa,” said Musavuli, referring to the continent’s brain drain. Musavuli doesn’t think about leaving Africa, personally: “Life is where you are most useful.” He enjoys doing all types of surgery here: orthopedic, pediatric, sometimes even neurological. “If I go to the U.S., I will be useless!” he laughed.

With the anesthesiologist watching, Musavuli (middle) repairs a leg fracture with the help of an intern and a scrub nurse. Carielle Doe

LIBERIA, A COUNTRY OF 4.9 MILLION, has few surgeons. Civil war and then Ebola decimated the medical staff in the country. Many died, and some left. Replacing staff takes many years and much investment, especially training a surgeon.

A 2011 survey of 11 Liberian hospitals serving the majority of the population found only three Liberian surgeons and no anesthesiologists. According to the survey, 21 doctors did most surgical operations.

Musavuli, who is Congolese, spent more than a decade in medical training. After medical school and an internship, he completed a five-year general surgery residency at a remote mission hospital in Niger to become a graduate of a Christian surgical training program, called the Pan-African Academy of Christian Surgeons (PAACS).

PAACS emerged out of the Christian Medical & Dental Associations but is now an independent surgical training program in faith-based hospitals across Africa. For 25 years it has cranked out African surgeons through clinically focused training and accreditation through African surgical colleges. The five-year general surgery residency takes place in remote hospitals, so surgeons know how to work in isolated places with limited resources.

African hospitals seek PAACS graduates because they know their level of experience, not only clinically but also in terms of comfort with working in ORs with flickering electricity. Musavuli also said that PAACS teaches you to know and be responsible for your patients, so you can present their cases every morning to the other staff without notes.

Currently PAACS has 105 residents in surgical training, and it has already trained and graduated 110 surgeons total who work in 21 African countries. One mission hospital in Kenya, AIC Litein, now has a surgery residency program entirely run by PAACS graduates. The graduates commit to serving in an under-resourced hospital for every year of training they received—so typically five years.

Liberia has fewer than 20 fully trained surgeons, according to PAACS, but six are PAACS graduates. Another Liberian, Dr. Aaron Kokulol, is on the verge of completing his surgical training through PAACS. That means this one Christian program has generated at least 30 percent of the surgeons in the country.

Liberia’s limited surgical care is true of the continent. Sub-Saharan Africa has the greatest unmet surgical need by population in the world, according to a 2015 report from the Lancet Commission on Global Surgery. Global health for the last two decades has focused on “individual diseases,” the Lancet Commission reported, while surgical care in poor nations has been neglected. Lack of surgical care resulted in almost 17 million deaths in 2010, according to the commission, whereas deaths from HIV/AIDS, tuberculosis, and malaria accounted for about 4 million.

ELWA had a functioning surgery department when other hospitals closed or suspended operations first in the Ebola outbreak. In the early months of the coronavirus pandemic, other Liberian hospitals halted surgical cases, and Musavuli watched ELWA’s surgical cases go up. Fortunately he had another PAACS graduate working alongside him.

The Musavulis outside their home. Carielle Doe

ONE DAY IN 2019, Musavuli was prepping for a splenectomy. As he searched for the key to the ultrasound room around the hospital campus, staff and patients would stop him every few feet with questions. He consulted about the case with missionary Dr. Rick Sacra, a fixture at ELWA who survived Ebola himself and oversaw a lot of the education efforts at the hospital. After discussing the condition of the patient’s spleen with Sacra, Musavuli said he wanted to make sure both a resident and an intern were in the operation, because it was a good case for them to see.

With the ultrasound room finally unlocked, Musavuli went to the woman awaiting the splenectomy and asked how she was doing. He said he wanted to do one test before the operation to make sure there weren’t any other problems.

“Can you walk?” he asked. He noticed she was struggling. “I will get you a wheelchair, that is much better.” As he crossed the various wards of recovering patients he said, “We have surgical patients everywhere!”

Musavuli completed his PAACS residency at Galmi, a well-respected but remote mission hospital in Niger. Galmi sits on the southern edge of the Sahara Desert, and although it is Christian, serves a mostly Muslim population. Musavuli remembered police and military protected the hospital because of sporadic violence nearby.

Demand for surgery was high, which was good experience for a resident like Musavuli. He recalled patients lying on stretchers and in hallways because the ward was always full.

“We couldn’t send them so far and say, ‘Go to other places,’” he said. The patients were poor. “When you face that, you have to do your best, with all the risk. It’s not ideal.”

Niger was a difficult post, with hot desert winds and a hostile environment and potentially deadly scorpions. One such scorpion clung to Musavuli’s towel when he was getting out of the shower and stung him, which was extremely painful, but he was thankful the scorpion hadn’t found his 1-year-old child at the time. His family had nowhere to go at the remote post, and there were no schools for his two children, another common problem for surgeons serving with their families in rural areas. He worked long shifts—early morning until 10 p.m. most nights—then would be on call thereafter.

“That is why all my hair is gone!” he said with a laugh.

Musavuli was among the first surgeons to graduate from Galmi. As he finished his residency, he wanted to go somewhere where the need for a surgeon was high, but also where he could teach. That’s a rare spot, because a hospital needs extra staff and infrastructure to support a teaching program. ELWA had a new teaching program and needed a surgeon. So he, his wife Sifa, and their two children moved 2,800 miles from their home in Democratic Republic of Congo.

Being away from extended family in Congo is another challenge for Musavuli, whose name means “savior” and who was the first doctor in his family. His parents never threw birthday parties for him since any extra money went toward school fees. After living through the Ebola crisis, his family in Goma recently had to evacuate when a volcano erupted there, sending lava flowing. He was anxious, but they and their house were spared.

On a more mundane level, flying from country to country in Africa is difficult and expensive, pandemic or no. He can more easily fly to the United States from Liberia than he can to Congo. When I met him in late 2019, he hadn’t been to Congo in four years. He missed his parents’ 50th wedding anniversary.

He would make more money too if he worked in a government hospital as opposed to a mission hospital, but he would be doing less work. And integrating faith into his work is important to him.

“When you look at money, you easily lose focus,” he said. “If you nourish your heart with those ideas, easily you will be broken.” He thinks mission hospitals could retain more staff by better supporting surgeons to provide education for their families, helping expats like himself travel to their home countries in Africa, and helping them attend medical conferences.

“As a person you want to fulfill your mission or your dream, but as a Christian there is also what God is expecting from you,” he said. “I say, ‘OK, I’m called to help those in need.’ … We received freely so we need to give freely.”

The ELWA surgery department, being entirely African, represents the PAACS dream, but Musavuli still thinks Western missionary doctors are a necessary part of the medical infrastructure. Surgical care is still so limited across the continent, and teaching hospitals especially need specialists to train in areas like orthopedics or pediatric surgery. A recent PAACS newsletter listed needs for surgical training personnel in its network hospitals across Africa.

“In countries with limited resources, there’s a high need for general doctors, but the need for surgeons is even much higher,” said Musavuli as he sat in an office between surgeries. An intern popped into the room to grab his belongings and left. “He will be a good doctor,” Musavuli said after the door closed.

Intern Dr. Krystle Ndupella (teal shirt) and Musavuli check on a patient on whom Musavuli had repaired a fractured leg the previous day. Carielle Doe

BACK IN THE OR, as Musavuli was working on removing the massive spleen, he taught another intern. The surgery was long. He and the surgical technician discussed the differences between the making of Liberian palm wine and Congolese palm wine. After three hours of careful work, the huge spleen came out. The patient recovered over the coming days. Musavuli said they didn’t have the materials they needed for the surgery, but “we try to manage.”

The first few months at ELWA, Musavuli, a French speaker who is fluent in English, struggled to understand Liberian English, a pidgin English with its own phrases and idioms. The Liberian doctors also understand certain cultural concerns with patients more quickly than he does, but he understands Liberian cultural concerns more easily than an American surgeon.

He also knows the shadow of Ebola that has hung over Congo, and the surgical staff at ELWA had that hanging over them too. Many of them worked in the Ebola units at ELWA and still remember the fear that came with it: Ebola killed operating room staff too.

Oretha Paye, a nurse working in the operating room with Musavuli, watched three nurses die from Ebola in the 2014 outbreak. She continued working even though she was “always afraid,” and she knew it put her family at risk. “This is something we have to do, because this is our calling, and we have to save life,” she said.

When the coronavirus pandemic hit, Musavuli felt that ELWA was well prepared to function because of previous crises like Ebola. The hospital had a lot of personal protective equipment (PPE) stocked up at the beginning. After about three months passed, the hospital began running low because personal protection equipment was in demand around the world, and now the hospital is struggling to keep supplies stocked. Musavuli and his staff use the wrong size gloves for operations regularly. For a time they were low on sutures, he said.

Musavuli’s wife Sifa contracted COVID-19 at one point but recovered. Musavuli himself never tested positive. The hospital had to convert its female ward into a respiratory ward, squeezing patients into other wards. Cases recently have been rising despite little testing, straining ELWA’s oxygen supplies. Meanwhile the number of surgical cases has returned to normal, according to Musavuli. In August, ELWA was able to begin distributing doses of the Johnson & Johnson vaccine against COVID-19.

“It is a battle, but God will provide with time,” Musavuli said over the phone, at the end of a recent day of surgery. The clatter of hospital activity sounded in the background, and staffers threw questions at him as he prepared to return home for the day.

—Emily Belz is a former WORLD senior reporter