Imagine having only 1 pediatric surgeon in your city, county, or state of over 4 million people. Worse, that surgeon would be responsible for not only gastrointestinal problems, but also most urological, vascular, thoracic, ENT, plastics, and neurosurgical problems. Overwhelming, right? Such is the problem faced by most of sub-Saharan Africa. That is the burden being addressed by the Pan-African Academy of Christian Surgeons (PAACS), an organization training general surgeons, other specialty surgeons, and anesthesiologists across Africa.

Faced with the enormity of this burden that would outlast them, career missionary surgeons in Africa founded PAACS in 1996 to tackle the problem. Their mission was to train African surgeons who would commit to staying in Africa, mostly in rural locales. The training would take place in mission hospitals across Africa in the form of a 5-year residency. The first surgeon graduated in 2002 from the Bongolo Mission Hospital in Gabon and went to serve in his home country of Madagascar. PAACS programs soon began to multiply, staffed by career missionary and locally trained surgeons, using a contextually relevant curriculum, accredited by Loma Linda University and the College of Surgeons of East, Central and South Africa (COSECSA), and collaboration with the West African College of Surgeons (WACS). Now 20+ years from its beginning, over 142 surgeons have graduated, honored their commitments to stay in Africa, and are contributing significantly to the health care of an entire continent. Their stories are legendary, some of which can be found at the PAACS.net website. Currently, PAACS training programs are in 17 hospitals in 11 countries and comprise 14 general surgery (1 new program next year) and 10 specialty programs. Specialty programs include pediatric surgery, orthopedics, cardiothoracic, neurosurgery, plastic surgery, anesthesia, obstetrics-gynecology, and head-neck surgery.

Notice that urology is absent from the list of specialty programs, but not for long. That is because the need for urologists in Africa is great. PAACS program directors estimate that the number of urology patients which general or pediatric surgeons care for ranges from 30% to 45% of their workload. To address that need, a team of PAACS urologists is investigating the possibility of starting 1 or more urology residency programs in the PAACS model. The first program will likely start in Kenya, alongside one of its general surgery programs. Initially, urology trainees will have completed general surgery training prior to entering a 3-year urology fellowship. This will allow graduates to provide both urology and general surgery staffing at other PAACS surgery training hospitals where general surgery needs are still paramount. Future consideration includes creating a 5-year residency (2 years of general surgery, 3 years of urology), depending on the need of the region where the graduate would serve.

Pediatric urology training has been at the heart of the PAACS Pediatric Surgery Fellowship program, which started in 2005 at BethanyKids/Kijabe Hospital, about an hour north of Nairobi, Kenya. Its curriculum includes an extensive amount of pediatric urology as most pediatric urology in Africa is done by pediatric surgeons. Several pediatric urologists from the US (including this author) have worked with the staff pediatric surgeons at Kijabe to train the fellows in management of congenital urogenital anomalies, trauma, cancer, and infectious/inflammatory diseases. The 3-year fellowship program has graduated 14 pediatric surgeons and is looking to start new programs in other countries as well. The BethanyKids/Kijabe program now includes a 5-year residency (2 years of general surgery, 3 years of pediatric surgery) as well as the 3-year fellowship (Figure).

Figure. Author (third from right) with pediatric surgery team at BethanyKids/Kijabe Hospital, with photos of past graduates.

As programs expand, so too does word of PAACS’s reputation for caring and excellence. And the patients come. From everywhere. By foot, cart, scooter, rail, car, or packed minibuses. The volume of urology cases at the training hospitals does not appear to be diminishing, nor does the acuity of these problems. At BethanyKids/Kijabe Hospital, where the pediatric surgeons are now comfortable with most pediatric urology patients, visiting urologists rarely enjoy the luxury of doing a routine hypospadias or other relatively minor problems. Instead, they are greeted with problems like severe stricture disease from pelvic/perineal trauma, redo hypospadias and exstrophy, and other challenging reoperative cases. These challenges provide wonderful training opportunities not only for the pediatric surgery fellows and residents and the program faculty, but also for visiting specialists who find themselves outside their comfort zones and reliant on the skill and innovation of the faculty surgeons who are deeply committed to training their proteges.

PAACS enjoys its growth and success not only because of the committed career surgical trainers across Africa, but also because of an administrative organization that is highly engaged in providing program oversight and guidance, vision, curriculum development, and financial and spiritual support. A small army of volunteers give time and treasure to support the programs. Visiting faculty find that the time spent at the training sites yields far greater reward for the visitor than the trainees. The life of this surgeon and author has been forever changed by working alongside PAACS surgeons and trainees who are so deeply committed to the vision of caring for the people of Africa. One day soon, urology training programs will also be able to partner in the PAACS’s vision for Africa.

For those who want to learn more about opportunities to get involved with PAACS, please see PAACS.net.