Here in the rural interior of Burundi in January 2020, a 5.5-pound baby was born with part of his small intestine outside of his body. He needed an operation. Without general anesthesia, surgery was impossible, and managing anesthesia on a tiny baby is extremely difficult. During intubation, too much fluid from the saline drip will kill a baby that size. Also, turning the ventilator on with adult settings could explode the baby’s lungs. And a baby is prone to hypothermia, so anesthetists have to manage the baby’s temperature carefully. Anesthetizing a baby requires vigilance and the calm that comes with experience.

The parents brought their baby to Kibuye Hope Hospital, a rural church hospital with two hundred and fifty beds at the end of a dirt road lined with banana and eucalyptus trees. Kibuye had on staff an American missionary anesthesiologist, Dr. Greg Sund, but he was traveling for the day. Anesthesiologists are physicians trained in anesthesia who have years of surgical training to manage such difficult cases, and Greg was the only anesthesiologist in the country of twelve million outside of the largest city of Bujumbura.

But Kibuye also had Berchimas Ndikumana, one of its team of non-physician anesthetists, a specialty often performed by nurses with advanced training. Berchimas – who grew up on the hill next to the hospital, is the second oldest son of farmers, and writes gospel music in his spare time – knew how to give general anesthesia to a tiny baby. In the United States, that’s an area where nurse anesthetists need special instruction.

Berchimas successfully intubated the fragile baby, managed him through surgery, then carefully wiped the baby clean from the goo used for monitors during surgery, and woke him up. He bundled the baby in a cloth and carried him out to his parents in the recovery area.

“When you’re used to it, it’s easy,” he said in French.

Two weeks earlier, a four-day-old baby arrived at the hospital. The baby hadn’t pooped since birth, likely from a birth defect, and therefore had a massive belly with her delicate skin pulled tight. That created a high risk for vomiting and aspirating during surgery. Gloria Iteriteka – an anesthetist who grew up next to the hospital, went to primary school with Berchimas, and prays before she starts each day at the hospital – managed the baby’s general anesthesia. Dr. Jason Fader, an American missionary surgeon who has lived and worked at Kibuye since 2014, did the surgery alongside her.

“She nailed it,” said Jason. “And the baby is alive. Six years ago, the baby wouldn’t have a chance.”

Kibuye, the primary teaching hospital for Hope Africa University’s medical school, had no capability to do general anesthesia in 2014, but now it has perhaps the best anesthesia care in Burundi outside of Bujumbura. Kibuye’s anesthetists are good because Kibuye is a teaching hospital.

It has become a pipeline of medical talent, pumping out doctors and nurses who are trained – and motivated by their faith – to work in a tough rural environment with few resources. When foreign governments and foreign humanitarian organizations ordered staff home from Africa in the pandemic, the missionary physician specialists doing training in Burundi largely stayed. And the growing national staff of anesthetists offered more long-term institutional stability.

Most of Burundi’s medical care is concentrated in Bujumbura, and most of its twelve million people live in the countryside. Good anesthesia care is a big deal for an area that one surgeon once described to me as one of the most “surgically desolate” places on earth. It’s also important for sub-Saharan Africa, where poor anesthesia care contributes to an extremely high mortality rate for women having C-sections.

The World Federation of Societies of Anesthesiologists (WFSA) recommends a minimum of five physician anesthesia providers per one hundred thousand people. By that standard, there should be about six hundred anesthesiologists in Burundi. Burundi has six anesthesiologists, according to the WFSA. Anesthesia staff in the country reported to me that that number now is down to four, and all four are in Bujumbura. Four anesthesiologists for twelve million people. The United States has twenty-eight thousand six hundred anesthesiologists, according to the Bureau of Labor Statistics. Without anesthesiologists, training good anesthetists like Berchimas and Gloria becomes even more important.

Faith-based hospitals in sub-Saharan Africa are an underrecognized resource for training national staff, as they are largely church-run teaching hospitals now. They are developing high quality national staff and specialists, but few have noticed. Faith-based healthcare providers “have been neglected by the worlds of research and policy for decades,” wrote a group of public health researchers in The Lancet in 2015. “They are not simply a health systems relic of a bygone missionary era, but still have relevance and a part to play (especially in fragile health systems).”

In 2014, Jason was the only surgeon at the hospital and for millions in the area, with one anesthetist. He and the staff would have to improvise on weekends or whenever the one anesthetist went on leave. Staff were “trained on the job and could put a spinal in,” Jason remembered. “You could probably do a C-section.”

Joseph Nibigira started work at the hospital in 2015 as an anesthetist, and remembered doing ketamine instead of spinals for surgery, a riskier option for anesthesia.

“We were very limited,” said Joseph in French. Here he was five years later, talking in the middle of managing general anesthesia for a patient with a fractured hip getting a surgical nail inserted. Ketamine “caused a lot of problems in surgery” and added risks of aspiration, he said. With ketamine, he couldn’t have a conversation in the middle of surgery like we were having, because he would be anxiously monitoring the patient every second. Sometimes the patient would start moving after fifteen minutes and he would have to give more ketamine.

With full-time anesthesia training from Greg the anesthesiologist starting in 2017, the anesthesia department grew. From 2018 to 2019, the hospital’s volume exploded thirty-four percent with pent-up demand for medical care. In 2016, Kibuye was doing two thousand major surgical operations a year. In 2019 it did three thousand one hundred. The hospital hospitalized eight thousand four hundred patients in 2018, and ten thousand five hundred patients in 2019. When I asked Jason, who serves as the hospital’s chief medical officer, how the hospital volume grew so much in one year, he told me the question was backward. The question should be: How did the hospital not grow more?

“The growth is unlimited,” he said. “We hospitalized ten thousand patients. The need is one hundred thousand.”

The staff to expand the hospital’s capacity take years of investment in training. Berchimas went to Hope Africa University, the Christian school in the capital affiliated with Kibuye, and did a three-month rotation at Kibuye where Greg taught him in the halls and operating rooms of Kibuye. When he finished school, Kibuye needed anesthetists, and so he came. Once at the hospital, Greg taught him more, like how to do nerve blocks.

“When I started working, I was afraid, but now with experience, I am never afraid,” Berchimas said. “Because I was born here, I was very happy to come here and help the patients around me. … Every time I remember what God has done for me.”

Rurally trained staff are also ready to improvise. On one Thursday in January, the hospital had a power outage as engineers worked on its relatively new solar power system. The staff who worked at the hospital for many years before any consistent electricity were accustomed to that, so surgical operations continued without general anesthesia.

A woman had come in with open fractures from a car accident, and without power they had to operate without the benefit of doing an X-ray first. In the darkened ORs, one anesthetist did a spinal block for anesthesia, and Joseph held a flashlight, while Jason operated. The next day she was recovering in the ward.

Working at a rural hospital like this is an act of service too: staff could make more money in the city, not a selfish consideration when these anesthetists support extended families. To work here, many staff members live several hours from their spouses and children, who don’t necessarily have work, school, or family in rural Kibuye. Staff members may see their families once every few months. Anesthetist Pamphile Muvunyi has a wife and three children who live hours away: “I miss them very much,” he said in French.

A number of the anesthetists shared a room together nearby to sleep at night. Berchimas, living at his grandfather’s house, would walk thirty minutes to the hospital for his shifts. Sometimes that walk was in sheets of rain or at night, which was scary in the pitch-black countryside.

“Working in the countryside, you just have to decide, ‘I’m going to serve,’” said Moïse Niyuhire, a doctor who was doing a post-graduation internship at Kibuye. He says that a surgeon in the city would make at least double what surgeons in the countryside make. And in the countryside, “there’s no place for your wife to work.”

Ask any of the anesthetists if they had a passion for anesthesia and you will get bewilderment. They do anesthesia because they succeeded in school, and they are competent in their jobs. Berchimas, as good as he is at anesthesia, doesn’t do it because it is his passion, he says, but to “serve,” and because he “must.” With his salary he pays the school fees of his six other siblings.

“We work as missionaries,” said Samuel Nizigiyimana, one of the anesthetists, who started the National Association of Anesthetists in Burundi, and does interviews on national TV and radio to share the need for anesthetists. He had just done anesthesia on a C-section case until 4 a.m., showered, and then came back for a later shift where he was now managing anesthesia on a hernia case. At Kibuye, “There is [medical] care, and the care of God. It makes the reputation of the hospital.”

But death is not uncommon here, with limitations of treatment for diseases like cancer. In such cases, good anesthesia care can be an important palliative. One Thursday at the hospital, a nurse came from a regional clinic, pushing an eleven-year-old patient in a wheelchair. The boy was weeping and moaning in pain. Cancer was taking over his body, his arm was swollen to three times its size, and the flesh had turned necrotic. The surgeons planned to amputate it as a palliative measure; the boy was going to die.

Greg discussed with the nurse – his parents had abandoned him, she said – and then gave the boy a nerve block so he could sleep that night at the hospital before his operation. Greg took a syringe of anesthetic medicine and with the help of an ultrasound machine targeted a particular set of nerves, teaching the anesthetists as he did it. He explained he was doing an interscalene block, blocking the shoulder down. The boy slept that night, but by the morning the block was already wearing off. Soon nurses took him into the OR for his amputation, and after the operation Greg gave him another block.

That day Greg did more upper extremity blocks with the anesthesia staff; once they would each do ten, he would give them a nerve block certificate. The next day, Pamphile, one of the anesthetists, did a nerve block in the OR and was thrilled: “It worked!” Pamphile didn’t know of other anesthetists in Burundi who could do nerve blocks.

With the goal of growing anesthesia training, Greg left Kibuye last summer to go start an anesthesiology residency at another faith-based hospital, Kijabe, in Kenya, through a surgical training program called PAACS. Kijabe already had a strong anesthetist training program. Within two weeks of announcing the anesthesiology residency plan at Kijabe, Greg had thirty applications for two resident spots.

It was hard for Greg to leave Burundi after six years, but it seemed like a good long-term vision to train more anesthesiologists rather than a nurse anesthetist here and there. More anesthesiologists could train more high-quality anesthetists. He’s hoping to recruit a Burundian doctor to come to the anesthesiology residency and return to Kibuye after.

The Burundian anesthetists stayed. Joseph ran the team. Berchimas, Gloria, Samuel, Pamphile, and others were all handling the cases alongside Jason and the other surgeons on the team now. It hurts the hospital to no longer have an anesthesiologist on staff, but Greg teaches over Zoom and answers questions from the anesthetists when they pop up.

“The team feels strong,” Joseph said. “Aside from Bujumbura, there’s no other hospital like this.”

Good anesthesia doesn’t solve the litany of other problems and heartbreaks of medical care in a rural setting with few resources. Dr. Ted John, an American missionary surgeon at Kibuye, did the surgery on the 5.5-pound baby where Berchimas smoothly managed the anesthesia. The surgery went fine but when he opened the baby, he was devastated to see a short intestine.

“These kids almost never survive,” he said, letting out a deep sigh. “They can’t absorb nutrition.” He tucked the intestines inside and closed up, and Berchimas woke the baby. Ted and the surgical team went on to the next surgery, a broken femur. Then Ted had another baby surgery, a baby that needed a colostomy to live. Pamphile managed the baby’s anesthesia while Berchimas got called to the emergency department to help with an IV. The baby survived.

One afternoon later that week, the surgery team – nurses, surgeons, anesthetists, technicians – had a celebration all together in the hospital canteen. They drank Fanta and piled plates with rice, potatoes, peas, and meat. Then Jason pushed his plastic chair back and gave an assessment of the surgery department to the room. He mentioned how much their caseload had grown. Then he shared three Burundian proverbs in Kirundi, the language of Burundi, which one of the Burundian doctors roughly translated to me. Jason told the room that you need three stones to have a cooking fire – you can’t have just one. It is better to do things together. And if you fail, little by little you will grow better.

After the meal, they all went back to the operating rooms.