September 1993 – Vol.9 – No.4
In some of our visits this furlough, people have asked for a better description of the hospital work in Mozambique. Marrere is a 100 bed general hospital though it has the capacity for an additional 20 beds. It has a staff of one doctor; one administrator; 35 nurses, midwives, and technicians; as well as 30 servants. After seeing the picture of it in the last Mozambique Evangel, nearly everyone is amazed to discover it is a large, well built facility. Apparently I have understated its “grandeur” in these letters by calling it a rural hospital. Before independence, it was in fact the “hospital deluxe” for all of north Mozambique and the preferred medical facility for those who could afford it. Its pleasant, rural location five miles outside Nampula gives it a quiet, restful, almost resort-like atmosphere.
When the Africans gained independence from Portugal in 1975, the government confiscated it from the Catholic church who originally intended to use it as a boarding school for ministerial students. That explains why the center of the building is a huge, 4,800 square foot chapel with a forty-foot ceiling.
Jutting out from either side of the chapel are the north and south wings. On the ground floor of the south wing is the outpatient clinic. The nurses, midwives, medical technician, and I see about 1,600 patients each month. Patients who wish to be seen on a given day must be present by 8:30 AM. After signing in they wait in the chapel area where several of the pediatric clinics are held. Because these patients are usually accompanied by family members who help them walk to and from the hospital, there is always a crowd waiting for us when we arrive. My heart longs to see an evangelistic message preached every day, applying life-giving medicine to the souls of the people assembled there as we tend to their physical afflictions.
The most common medical malady is malaria, followed by ancylostomiasis – infestations of tiny worms that live by the thousands in the intestines draining the blood of their unwilling hosts. Next is bilharzia, another infestation of worms that invade the skin during their microscopic larval stage. These worms migrate to the bladder and urinary tract where they grow to an inch in size and wreak all kinds of havoc within the suffering patient. These three diseases are practically universal in Mozambique. Added to these maladies are sexually transmitted diseases of every type, including AIDS. Unfortunately, there is no information on the incidence of AIDS in Mozambique. However, in some highly infested areas of neighboring Zimbabwe, tests have been positive for nearly half the population. In Mozambique’s Nampula province there is an unusually high incidence of tuberculosis, along with the usual urinary tract infections, pneumonia, abscesses, and malnutrition.
There is also a tragic paralysis that is the direct result of eating improperly prepared cassava or manioc root, the food staple here. This disease is common and had me and other western doctors stumped until a Canadian farmer (actually an agricultural engineer) working for World Vision diagnosed it for us. To date, everything I know about it I learned from reading one of his agricultural journals. Sadly, the paralysis is irreversible and untreatable.
All the clinics, except one, are done by noon every day, if not earlier. The exception is the surgical clinic which is held only one day each week. Since, as many as 120 patients may show up, we run non-stop till all have been seen. My assistant and I are often still there late at night, working by flashlight, hours after the rest of the hospital (and the electricity) has shut down.
Our patients suffer along with us, since they arrive early and must get through the day without meals, faced with a long trek back home in the dark if they are among the last to be seen. At the end of each day I fill the Land Rover with as many patients as possible since it is unwise to walk through the bush at night. My assistant in the clinic always gets the next day off.
It isn’t necessary to make my clinic so demanding, but by doing it this way, I keep my work week down to four days, or about 35 hours. That leaves time for the spiritual ministry which must have priority. No surgeon operating in the US could see 100 outpatients, do 25 major operations, make regular rounds on 30 to 35 inpatients, maintain reasonable medical records, and still work just 35 hours per week. That is the efficiency of missionary medicine! Of course part of that is because Arnaldo has been trained to stand in for me on most of the simple operations. This is accomplished by scheduling only hernia and hydrocele repairs on my clinic day. By the time I am done with the clinic downstairs, Arnaldo and the OR team have finished eight to ten operations upstairs!
Besides hernias and hydroceles (fluid accumulations in the scrotum that reach the size of small melons), the most common surgical problems include: benign tumors of the uterus and ovaries; bowel obstructions and gangrene; elephantiasis; burns; snakebites; tumors and overgrowth of the thyroid gland; damage to the urinary tract from the bilharzia worm that makes it’s home there; and complications from child birth (where the rectum, bladder, and reproductive tract are so damaged that they all form one large incontinent opening). On top of all that, when compared to illnesses here, everything in Mozambique presents itself on a grand scale. Many patients have suffered for decades without access to surgical care, so when they show up their problems have reached gargantuan proportions. Huge hernias are the rule, for example, and it is not unusual to operate on men whose scrotums hang to their knees and have to be carried in slings because the entire large bowel and most of the small bowel resides there, along with two or three hefty hydroceles. Of course from the waist up they look great – no belly!
Thyroid, uterine, and ovarian tumors are almost never small and neat either. A wise old surgeon once told me his daily prayer was, “Lord, spare me from the interesting case.” It is always the unusual case that bites back, so to avoid problems it is best to handle as few “interesting cases” as possible. You can imagine my chagrin when, during the first months in Mozambique, almost every case that came to me proved to be “interesting.” Of course over time these cases have become routine. The sad consequence of this is that some of the more common cases performed in the US would now be difficult since I never encounter them in Mozambique.
Directly above the clinic in the south wing is a twenty bed maternity ward served by a staff of seven midwives. They attend about 140 deliveries each month. At the onset of labor, a pregnant woman must endure a long walk to the hospital. If the distance is too great, she might not make it at all. On several occasions I have been called to help women who had delivered their baby in the street or in the bush while trying to get to a health post. To avoid such an outcome, the more fortunate women arrange temporary lodging near a clinic as their due date approaches. Thankfully, improving the conditions for childbirth is one of the major goals of the government health program, since the national infant mortality rate is 15%.
Down the hall from the maternity ward, on the second floor of the north wing, is the medical-surgical-pediatric ward with our surgical suite at the far end. Forty beds are available in this wing, which are increasingly filled by our surgical patients. Hoping to relieve this situation, the U.S. Ambassador has provided a grant to convert a building behind the hospital into a ward for ambulatory patients. When this project is completed, the capacity of the hospital will increase to 160 beds.
Back on the ground floor under the surgical ward is the TB sanitarium. Forty beds are devoted to these patients. Mozambique has one of the highest TB and leprosy rates in the world, and Nampula in turn has the highest incidence of both in the nation.
Tuberculosis is a difficult disease to treat because of the resistance of the organism. Patients must remain in the hospital for two months receiving three drugs daily. Then they are discharged with the proviso that they will walk to the hospital every week for the next six months to continue their treatments. Even for people living nearby this is not easy, but imagine what it’s like for those who have to hike twenty miles each way. Not surprisingly, there is a high drop-out rate in the outpatient program resulting in many relapses. The second time around the disease is more difficult to conquer than before, requiring more expensive medications and an even longer course of treatment. If there were time, a weekly Bible study for the TB patients would be invaluable. Those who participate could be taught much during their long stay in the sanitarium. Hopefully this will become a reality with additional missionary workers.
The hospital has a medical technician who is assigned to care for the non-surgical patients. In reality, little is done to ease their suffering or treat the complications of their disease. This is because Mozambican health workers generally succumb to a spirit of discouragement and apathy after their first few months in practice. The problems they face are overwhelming and the resources at their disposal are grossly inadequate. It is not hard to see why so many give up any hope of helping people. They soon begin to look at their job as merely a means of making their own life a little less difficult through the small salary they receive and their direct access to medications. Several times I have been called to see patients in extremis who had been in the hospital over two months without once being seen after admission by anyone other than the ward personnel. (This happened while a Mozambique-trained doctor was in charge of the ward.) The explanation for this negligent behavior is neither lack of time nor a heavy workload; the health care providers are always done for the day by noon and leave soon thereafter. Sadly, it is the result of a “minimum effort” mentally that arises from seldom seeing satisfying results when they do try.
One of the reasons we are seeking another missionary doctor to work at the hospital is because it is very unlikely we could find a local person who has not already been conditioned to function in this defeated, “minimal effort” mode. Grace Missions would scarcely want to accept responsibility for managing the hospital if the care provided there brought reproach to the name of Christ! Doctors trained in the West are accustomed to standards far higher than anything Mozambican health workers have ever seen or imagined. By God’s grace, a missionary doctor would have far greater ability to ward off the devastating effects of hopelessness when confronted with the extreme circumstances so common in Mozambique. It is because of God’s gracious provision that we have channels to supply what we need which the typical Mozambican health worker never enjoys. I hope to return next January with all the medications I could desire. Grace Missions plans to ship over equipment to give us full X-ray capabilities. We plan to set up the diagnostic lab which was donated three years ago. Given such a stark contrast, the apathy and hopelessness of the local health care worker is understandable.
Of course, the other reason we need another doctor is the great opportunity for using the hospital as a means of evangelism. The weekly evangelistic services, praying with the patients in the OR, evangelistic rounds on the surgical ward, and scripture distribution are but the tip of an iceberg compared to what could be developed in time. In addition, the spiritual needs of the Christians in the new church are great enough to keep two or three missionaries’ hands full.
So please continue praying for the families God may be preparing already for this mission field. If you know of individuals who would be interested, pass this letter on to them and invite them to give us a call! Grace Missions can be reached at (210) 657-6570.
Next month I’ll focus on the church ministry and the need for a full time pastor-teacher missionary. Until then, thank you for your continued prayers, support, and interest. We hope to contact you personally before leaving the States and look forward to visiting with you even if it is only by phone. We do appreciate your participation with us.
By His grace,
Charles & Julie