John Birky regularly saw children with HIV at the hospital in Zimbabwe.
Many of them were orphans because their parents had died of AIDS.
It tugged at Birky's heart.
"It was the most difficult group," said the 31-year-old doctor from the rural Kansas town of Goessel, "because you knew the life they had ahead of them. Africa can be very challenging for them.
"Just getting food day to day. Sometimes orphans are cared for by relatives who abuse them. Young girls are forced into prostitution."
Birky was in Zimbabwe last year as part of his studies through Via Christi Health's International Family Medicine Fellowship, a yearlong program that trains young family physicians to deal with the rare illnesses and often primitive clinical conditions they're likely to face as medical missionaries.
Such challenges are only lightly touched on if at all in U.S. medical schools, said Todd Stephens, a doctor who is the program's medical director.
Four doctors fresh from finishing their residencies recently began training in this year's class. It started in June with a two-month tropical-medicine course at the University of West Virginia's medical school.
In mid-August, the team split up. Marc Carrigan of Illinois and Dean Kubacz of South Carolina came to Via Christi in Wichita. Melissa Sandberg of Minnesota and Kristin O'Dell of Wisconsin began their field training at African hospitals Sandberg in Zambia and O'Dell in Zimbabwe.
After five months, the two teams will switch.
At Via Christi, the training includes spinal anesthesia, trauma surgery with emphasis on broken bones, ultrasound, treatment of burns, and dentistry through GraceMed.
"They do rotations that would be out of the box for typical family medicine," Stephens said.
Mission medicine could mean pulling a tooth. Burns are frequent in third-world countries, since most cooking is done over open fires.
"Trauma is a daily occurrence," said Stephens, 48.
'Pushed out of my comfort zone'
He speaks from experience. Long before any such program was available in this country, he was living as a medical missionary in the 1990s. He spent two years in Kenya and four years in Rwanda.
"Not a day didn't go by that I wasn't pushed out of my comfort zone," Stephens said. "You learn to live and function in a resource-poor setting. You have to make decisions like who gets the one oxygen mask."
He removed a kidney, a procedure he had never done.
"We read about it just beforehand," Stephens said. "We did that a lot reading and praying."
He returned from the field in 2002 to go back to his hometown of Minneola and join his father in a family practice. In 2006, he was contacted by doctors at Via Christi who wanted him to help start the international fellowship program.
It was launched in 2008. Students receive $25,000 for the year about half what they got annually during their three-year residency program.
"This thing is lean," Stephens said.
After being privately funded the first three years, the program has joined with Via Christi Foundation and Via Christi Solutions for financing this year. It costs about $58,000 to train and send a doctor into the field during the fellowship year.
Via Christi Solutions, which helps support care in rural areas, draws help from the program. The four international fellowship doctors spend one-week rotations at rural Kansas hospitals four times during their five-month stay in Wichita, adding up to 16 weeks of coverage.
In return, Via Christi Solutions pays 90 to 95 percent of the program's budget, Stephens said.
"It's a win-win for all of us," he added.
So far the program's graduates haven't been able to go directly into medical missions, because they are practicing in rural communities across the country to pay off their medical school loans. Most states, including Kansas, have a medical loan program, which pays off a year of a loan for each year that doctor spends working in rural areas.
"There's about a four- or five-year hiatus while the loans are being paid off," Stephens said.
Outgrowth of faith
That's where Birky finds himself today.
He finished the international fellowship program in June and began working at Kearny County Hospital in August. He will be there at least three years, but he will be allowed to leave up to one month each year to go overseas.
Birky was attracted to medical missions after hearing stories from a great-uncle, John Schmidt, who worked with leprosy patients in Paraguay in the 1940s.
During his college years, both as an undergraduate at Kansas State University and then at the University of Kansas medical school, he went to South America and three times to Africa.
"Medical missions is an outgrowth of my faith and desire to help people who are in need," said Birky, who is married with two young children. "There are significant areas of the world that suffer from lack of medical care."
Birky spent his field time in Zimbabwe's Karanda Hospital over the last five months of 2010. He was joined by his wife, Lisa, and their son Jude, who was 1 at the time.
Two graduates of the program, who were doing rural practice in Iowa, joined him for his first month and final month.
Otherwise, Birky was the only doctor at the hospital except for Roland Stephens, a general surgeon who is in his early 80s and has been in Zimbabwe almost constantly since the 1960s.
Birky's days were long. Seeing 100 patients daily was normal. On days set aside for surgery, he would perform five to 10.
"It could be exhausting," he said. "But, honestly, the pace of life there was different than America. Electricity wasn't consistent. People would go to bed earlier and then be up at 5 a.m. By the end of the time there, we had adjusted to it and found we kind of liked it."
Besides HIV, Birky saw plenty of tuberculosis cases. Children came in with swollen brains, which needed to be drained. Skin ulcers, tropical diseases and fractures were common.
Training can prepare you only so much.
"You can never fully understand it until you are there," Birky said.
Looking to expand
Todd Stephens spent a month in Africa in 2006 and has gone there for a few weeks each year since in 2008 to see how things are going.
Sometimes he gets the itch to do it full time again.
"I see the great impact and influence on this generation of doctors that this program is having," he said. "That's what keeps me here. But, yeah, I'm a little restless."
Right now, he's focused on expansion.
All of the field training for those in the international fellowship program so far has been at African hospitals. Stephens hopes to work with hospitals in Central and South America by 2013.
The program's size is limited by how many can be accommodated during the Wichita segment, which is four. He would like increase the class size to six, a move that would require administrative approval from Via Christi.
"I certainly think the rural hospitals of Kansas would appreciate us increasing our numbers," Stephens said.
He already has 11 applications for next year's class.
As for Birky, he's also eager to return to the field. For now, his annual one-month trips overseas will have to suffice.
"I really enjoy Lakin (in Kearny County), the full spectrum of family practice," he said. "There are needs everywhere... Lakin, Africa, South America. I just want to do what I can to help wherever I am."