I was sent as a priest and a general surgeon to Zambia in 1993 as part of a general outreach of our religious organization (I am a Catholic priest in the Jesuits). I thought the assignment might be for 1 or 2 years, but I am still at work in this region 30 years later. It has been a challenging placement on many levels.

I had figured that my general surgical training, subsequent surgical oncology fellowship, and experiences and management in the intensive care unit had prepared me for a wide variety of clinical issues. I had worked in a few academic medical centers for about 10 years after fellowship before I went abroad. I did feel fairly confident in handling an array of surgical problems, and I felt fairly confident of my ability to adapt to different institutions. And surely it has been true that all that preparation in the United States did prepare me well for life and service in these subsequent years. But the specifics of the journey have been unexpected—that’s where faith insists on searching for God’s ways in all the uncertain circumstances that unfold.

First of all, there has been and continues to be the important exploration of a different culture. I began my assignment at the University Teaching Hospital in Lusaka (Zambia) and was introduced to their regular pattern of surgical services managing their own ward and taking emergency call in turns for 24-hour periods. Early on, I remember feeling particularly good one morning as I made rounds for our old patients and the ones just admitted in the previous day; I thought we had done excellently well in managing several emergencies and the general busy evaluations of the day. But one of the matrons called me aside and asked me to come to the office in the afternoon. There, 4 matrons mentioned to me that although we had taken care of a number of patients fairly well, the surgical theater staff of the night and myself had not had the appropriate break and rest. I objected to the assessment, suggesting that actually everyone had had a break of some sort and there had been a great number of patients needing surgical assistance. It was then explained to me that we had taken individual breaks, but not a break together. I also remember several department meetings during which I struggled to understand how we moved toward consensus in the management of specific surgical problems. Both experiences have moved me to live through a different experience of togetherness than I had known.

Secondly, there have been professional challenges. I mentioned that I had felt confident in managing the ordinary array of general surgical issues common to an American surgeon. The implications of not having many surgeons in the country did not occur to me until I was asked to manage orthopedic problems and urology problems and some pediatric problems and even some neurosurgical problems. I knew there weren’t many specialist surgeons, but it had not occurred to me that I myself would have to learn to manage many of those problems at a certain basic level. After many years now, I will readily say that I do not cover the extensive sophisticated management of those specialities, but I can have a more intelligent conversation than I was able to have in those earliest years. I focus on some problems, and I pursue training through reading and workshops. And then we try treatments with informed consent of the patients, our own good will, and relying on the merciful healing abilities of the human body. Currently, urology problems of an obstructive nature (ureteropelvic junction obstruction, prostate hyperplasia/cancer, urethral stricture) are a focus for us. The referral system simply does not manage the large numbers of patients in trouble. With some careful selection and consultation with recently trained urologists, I participate in task sharing helping these patients on a general surgery ward. And I can involve my team of clinical officer surgical specialists in this work.

Thirdly, there have been social challenges. I have kept up my medical license in the United States although I have not practiced there for a long time. This past year one of the continuing medical education requirements was a few hours on “diversity.” To my surprise, the material was very engaging and made me think more deeply about my efforts to adjust and my difficulties in adjusting to the cosmopolitan experience of dealing with many people from different nationalities and different social experiences who have all come to participate in international medical care efforts. Broadly speaking, we do share humanitarian goals, but we differ a lot because our families and ourselves have different journeys of life. We are engaged in some different searching in those journeys.

So what do I do now? I work with the College of Medicine (Kamuzu University College of Health Sciences) in the surgery department. Over the past 15 to 20 years it has been a common effort in this region to explore task sharing of many clinical services including surgical services with nonphysician clinicians. The basic intent is to provide what WHO describes as essential surgical services in this part of the world where there are very few facilities to provide health care. It is an ongoing challenge to figure what surgical services we ought to deliver and then all the various components that go into accomplishing those goals. As a university, we start with considering how to educate the human resources to a higher level. But there are also material resources needed in the hospital (supplied partly by the government ministry of health but supplemented by various well-wishers and private sources). And there are the logistic issues of transport and communication among the various levels of health posts, health centers, hospitals, and central referral hospitals. And then there are the local economy issues of food supplies and transport for patients and their families. And there are the concerns for home care after surgery. Those are the basic concerns.

There are layers of evaluation that have developed over these years. We consider success on many levels. There are the numbers of surgical procedures now able to be performed throughout district settings. There are also various social reports from communities expressing satisfaction with development of local hospitals and easier/better access to services. And there is the general empowerment of young health care workers happy with their new skills, confident of their clinical analysis, and committed to making a better future (Figure). Although the sense of hope among young people is rather intangible, it is perhaps the most important factor driving progress forward. These days, I think encouraging the search for a hope-filled future among the young health care workers is my most important task.

Figure. The bachelor of science general surgery alumni meeting, July 2023.

Overall, it has been a great privilege to be part of this particular effort. There are many different projects that can stimulate ideas of service, of cooperation, and of development. Some have a clear religious dimension; others seem simply humanitarian. I urge all readers to explore a venue that fits with their background, time, and energy. The search itself always expands—and the search breaks open more ideas about the mystery and wonder of the world.