Celebrating with the residents after the test

Jack Barasa, PAACS resident from Kijabe Hospital, Kenya, was awarded a medal for the highest score on the MCS exam
Mass grave from the genocide massacre, 1994. 250,000 bodies are buried at this memorial.


Most of the residents and I have been in Kigali, Rwanda, for the last week. Soddo Christian Hospital had four residents taking a certifying exam with the College of Surgeons of East, Central and Southern Africa (COSEC SA). In addition, PAACS as a whole had a total of nine residents or fellows taking exams with COSECSA at Kigali. There are two levels of testing: membership (MCS) and fellowship (FCS). Two years of training are required for the MCS level certification. An additional three accredited years are required to take the FCS exams in the various specialties covered by the College, including general surgery, orthopedic surgery, plastic surgery, urology and pediatric surgery.

This was an important event for the growth of PAACS as an institution. A major challenge PAACS faces in the African setting has to do with a fundamental understanding of how surgeons should be trained. Essentially all of Africa has adopted the British system of training which is heavily centered on universities and associated with academic degrees. PAACS, however, is based on the American system which focuses more heavily on clinical practice. In fact, in the United States around one third of all the surgical residencies are not associated with universities but are considered “community based.” University based training is still important but there is a lean towards a both/and policy of training as opposed to either/or. PAACS is operating under the “community based” model.

It is difficult to claim that either system, British or American, is inherently superior because both produce well-trained surgeons who are competent, qualified physicians. But they have a different feel and introducing one in the territory of the other can cause discomfort.

In the end, results speak the loudest and it was important for PAACS residents to do well in these tests. Overall, I praise God for how we did. Though we have room for improvement, it was positive on the whole and a vote of confidence for PAACS. Eight residents took the MCS exam and seven passed. One fellow took the FCS exam but he did not pass. I’m encouraged that we are on the right track but feel a sense of urgency to seek improvement. It is truly by the grace of God that we have accomplished what we have and we will need His strength and wisdom to move forward from here. It is always a humbling experience because the task is truly too large for us.

I’ve enjoyed visiting Kigali for a little while. It is a beautiful city; probably the cleanest I’ve ever seen in Africa. The people are friendly and I hope to come back and visit again someday with Becca and the kids. We visited one of the genocide memorials one day. It was heart-rending. It’s incredible to imagine that only fifteen years ago so many thousands of people were slaughtered. The death toll on women and children during that horrific time was especially nauseating. As we drove back to the hotel, our taxi driver opened up a little with one of the guys who spoke French. He shared that he was twelve years old when it happened. He watched his parents and siblings murdered and then spent three months hiding in a ditch, coming out only at night to forage for food. He confessed that the country was a long way from being healed.

The depth of human depravity is overwhelming. How quick we are to exclaim that such behavior is impossible for us and yet the story has been repeated so many times in so many places around the world. The illusion of civilization is thinner than we like to think.

Two thoughts in particular struck me as I walked around the exhibits. The first thought concerned the proposed solution to preventing further such atrocities. Everywhere in the exhibit education was hailed as the answer to combating evil. I do not understand our determined tenacity to hold onto this hope. The twentieth century saw the greatest advances in education ever seen in the history of the world and yet it was full of blood. There were two world wars, a holocaust, millions of people were killed under Stalin’s leadership, millions more under Mao Tse Tung, genocide in the Balkans, two genocides in Rwanda, genocide in Sudan and countless other atrocities in every country. Do we have any evidence at all that knowing the right thing to do has ever been a sure defense against doing the wrong thing? Is not the evidence of our own personal lives that we tend to choose the wrong thing we know we ought not to do if the temptations and external environment are strongly conducive enough?

I’m not saying that strongly ethical and even sacrificial behavior is not found among unbelievers. Not at all. In fact I’m often humbled and inspired by such people. I’m simply saying that education is not a convincing explanation. We don’t need smarter brains but softer hearts.

The second thought that struck me was magnitude of justice and wrath that was poured out on Jesus at the cross. As I looked at the pictures of piles of bodies (men, women and children), read the stories of children forced to watch their parents and siblings raped and murdered before being raped and murdered themselves, my anger burned in me. I can’t imagine the punishment that would be sufficient to pay for such behavior. When I then thought of the magnitude of iniquity seen over the history of mankind, it blew me away.

When John the Baptist first saw Jesus, he said, “Behold, the Lamb of God who takes away the sin of the world!” I am again staggered at the magnitude of wrath and punishment that Jesus took on our behalf at the cross. The Bible says it was actually sufficient to pay for such evil. Then to think that He did it for the very ones who deserved the punishment. Amazing.