“It seems like you’re telling me that there have only been a few people who have succeeded, and you’re saying that I really won’t be able to follow any of the paths that led to their success.”

This statement summed up a conversation I had when I first embarked on working with my Mozambican collaborators to establish an emergency medicine residency program in Mozambique, and it not only accurately reflected the conversation I had just had, it in fact foretold what the next few years would bring – the uncertainty, the feeling of always charting our own course, and the frequent feelings that all of our work would turn out to be for nothing.

During that discussion, I learned that the few successful examples of EM programs in low-income countries all involved early and generous financial support from an outside funder or a sponsoring non-governmental organization. No one, it seemed, had started as we were attempting to do in Mozambique – armed with no financial support and staffed only by determined physicians who were volunteering their time to the project.

Soon after that conversation, my Mozambican collaborators and I sat down to a meeting with the director of the Mozambican Medical Board, and tried to convince him that emergency medicine should be recognized as a medical specialty. 

The ability to be recognized as a “specialist” has wide-ranging implications for Mozambican physicians – determining everything from professional autonomy to annual salary – and the meeting did not go well. I felt the future of EM in Mozambique slipping away as the director asked incredulous questions like, “Can’t generalist physicians do all of this?” and “Does it really take four years to learn emergency medicine?” 

We left deeply demoralized, and this really might have been the end of the history of emergency medicine in Mozambique, if another our allies hadn’t been this director’s ex-wife, who a few days later stormed into his office and somehow convinced him to approve our petition.

The specialty designation didn’t end our challenges; far from it. The subsequent months involved multiple rounds of revisions and edits to the EM residency curriculum, trying to please multiple stakeholders who often had conflicting opinions about what the final product had to include. 

Then, a few months later, we finally had our first class of residents – six Mozambican doctors brave enough and determined enough to sign up to train in a specialty that had never before existed. 

Unfortunately, shortly after the residents arrived, we were told that they had not yet been allowed to start clinical rotations at the country’s central academic hospital.  The residents arrived in March, and at that time I had a six-week old baby. Yet I was aware that in this country with a profound shortage of doctors, I could not squander even a day of these doctors’ time. 

So immediately we jumped into an intensive, didactic-based orientation to emergency medicine. Still groggy from life with a newborn, I begged for help in whatever form I could find it – emergency physicians passing through Maputo, US-based willing to give tele-lectures, and a tiny donation that allowed us to 

pay for Greyhound bus tickets so that the residents could attend an airway skills seminar in nearby Pretoria, South Africa. And then, abruptly one day in July 2017, we got a call that the residents could start clinical rotations the following Monday. 

Since the residency have started rotations, we have continued to face down challenges, but the headwinds have not been as fierce, and we have had moments of amazing luck. A grant to the government of Mozambique opened up travel scholarships, and the residents were able to spend six months training with the EM residency program at Muhimbili Hospital in Dar Es Salaam, Tanzania. Amazing EM colleagues have discovered our project and have joined us as wise advisors and tireless advocates, and generous donors have made it possible for us to begin to tackle projects that previously would never have seemed possible – such as offering trainings to generalist physicians and other health professionals who manage trauma, and for us to ship large donations of much-needed medical goods from the US to Mozambican hospitals. 

The path has been long and winding, and still there are stretches where the climb is steep and I lose hope that we will ever achieve all we set out to do. But more and more often, I find myself at small summits from which I can look around and appreciate how far we’ve come and how different that landscape is now than it was when we started.

If I had really listened during that first conversation, and truly understood how hard what we were trying to do would be, and how often I would feel that we were bound for certain failure, I might have given up before we ever got started. But despite the anguish and the occasional tears of the past few years, I am so glad I did not give up. 

In the end it has been exactly the fact that we stared down the impossible and persisted that has made this project the most rewarding and fulfilling work of my life.