Winning the Minister’s Approval

Fall 1996 – Vol.12. – No.4

“Seest thou a man diligent in his business? He shall stand before kings. He shall not stand before mean men.” Proverbs 22:29

Dear friends:

This is a verse I have more than once shared with the surgical team during the past term. They are a hard working crew and their productivity is enormous compared to their peers. Arnaldo and Jeremias, for example, recently churned out ten hernia repairs and eight hydrocele operations in only nine hours. In six years Arnaldo has never missed a day of work. All eight members of the team labor diligently. Yet our three nurses are each paid less than $30.00 a month (plus $60.00 from money earned through patient contributions), and the four orderlies receive between $20.00 and $25.00. For the orderlies, such as Jeremias who has eight mouths to feed on his pittance, the paycheck is gone by the third week, and by the fourth week there is no food to feed the little ones. When I say “food” I mean manioc root and dehydrated minnows, not rice, potatoes, or meat of any sort. When it seems hard work isn’t paying off and discouragement sets in, this is one of several verses from Proverbs I use in urging the team to remain diligent in their business. “God will stand behind His word,” I tell them, “if for our part we read it and be­lieve it. Your good work will not always go unrecognized. One day you will stand before kings if you just keep serving faithfully.” Then we pray and do not hesitate to remind God of reality as He has stated it in scripture.

Well, in the past month, God fulfilled that verse for the surgical team, and especially Arnaldo, in a literal and amazing fashion. I said in concluding our last report that “it will take a whole succession of extraordinary events for Grace Missions to establish its own health center.” Prepare yourself for the tale of extraordinary event number one. It will leave you overwhelmed at God’s power to order the events of men’s lives, great and small.

As usual this term, it all began in the furnace of affliction – actually, a few days before that, on July 24 when all appeared to be normal. Julie and I were reading the scripture portions for that day in “Daily Light on the Daily Path”. They dealt with being “patient in tribulation”. The last verse was John 16:33 which for reasons I did not then understand seized my heart and continued to inject itself into my thoughts for the next several days. This preoccupation must surely have come from the Spirit of God, which indwells every believer, for it was perfect preparation for what was about to take place in the ensuing weeks. The verse was this: “In the world ye shall have tribulation: but be of good cheer; I have overcome the world.”

The bombshell dropped on 6 August. For several days Marrere had been getting ready for a special visit from the Vice Minister of Health. Perhaps I should have had an inkling of foreboding when he appeared at the hospital with our arch nemesis Dr. Simon in tow. The visit was uneventful until the delegation reached the surgical block. Once the Vice Minister, Dr. Simon, the Provincial Director, city director, hospital director, and all the other chiefs and dignitaries were inside, Dr. Simon confronted the Vice Minister with the fact that Arnaldo was still openly and unabashedly performing operations at Marrere in complete disregard for the written directive from the Ministry of Health forbidding even his presence in the operating room. I immediately reminded Dr. Simon that the written directive was dated before the visit of Dr. Vaz, the head of surgery for the entire country. The Vice Minister rejoined that Dr. Vaz had nothing to do with the matter and that I was obliged to follow the directives of the Ministry of Health, not the opinions of other surgeons. The Provincial Director was right beside me and he was the one who had returned from the Ministry of Health with the information that the issue had been discussed at the Ministry and that Dr. Simon’s edict forbidding Arnaldo’s presence in the O.R. had been overturned. So I waited for him to untangle the situation, as he alone knew all the pertinent information, but he remained studiously silent. Dr. Simon seized the opportunity to resume his diatribe against the egregious practice he had discovered at Marrere that was now compounded by an utter disregard for the directives “from the Minister himself” (hyperbole on his part). I could not defend myself without deflecting Dr. Simon’s attack onto the Provincial Director, who has been our strong ally since January. Finally I interrupted with the comment that I could answer all of his accusations but preferred to discuss the matter in private and not in front of the surgical team and all the visiting dignitaries. The Vice Minister said it would be unnecessary to discuss the matter further as he would let the Minister of Health deal with me personally.

That ended the discussion and also the tour of the surgical block, which had only gotten underway. However, the Vice Minister walked out with the warning that the Minister would be unhappy with the report he would get upon their return to Maputo.

That evening I called the Provincial Director to find out how the tables had turned and to set up a private audience with the Vice Minister. He said it would not be possible to speak with the Vice Minister. Dr. Simon had been actively campaigning against Marrere at the Ministry of Health. He had turned the Vice Minister against us and apparently had convinced the Minister to support his position as well. Immediately I called Dr. Vaz to find out what exactly had taken place several months ago to get Arnaldo released from Dr. Simon’s restrictions. He was amazed when he heard of Dr. Simon’s attack that day. He said that after he spoke to Dr. Simon last November, the latter had promised not to raise the issue again. Apparently, that was the extent of the “fix” that Dr. Vaz had arranged at the Ministry. In reality, the verbal promise Dr. Simon offered Dr. Vaz with no written repeal of his former edict simply cast the surgical program at Marrere into an even more vulnerable position should Dr. Simon desire to terminate it, as he now seemed bent upon doing.

At this point it is important to repeat what regular readers of these chronicles already know, that because of the scarcity of surgeons in Mozambique, many nurses are authorized to do surgery (after completing an extensive training program) and they operate miles from any surgeon who could bail them out of difficulties should they arise. Arnaldo, on the other hand, only operates when I am present in the hospital. Moreover, the Ministry of Health has regularly received reports of Arnaldo’s surgical experience since 1992 and many people, such as Dr. Vaz, chief surgeon of Mozambique and former Minister of Health, the former Vice Minister, the former National Director of Health, and the former chief of Human Resources at the Ministry, all have known of Arnaldo’s work and given their approval, sometimes tacitly, sometimes enthusiastically. However, Dr. Simon was a general practitioner doing surgery in Nampula when I arrived in 1990 and opposed the creation of a second surgical center so near the city. He was later promoted to a high office at the Ministry of Health and has used his position to our detriment.

In a visit last year he insisted we cut our productivity by over 50%, saying that all operations had to be done by me. His written directive, which followed later, forbade Arnaldo from even scrubbing on cases. That meant I would have to do all my operations working entirely alone in the operating room, which essentially eliminated the other 50% of our output!

Once again, Dr. Vaz promised to campaign in our behalf to get the matter overturned. I assured him that I could not attend to the huge surgical case load at Marrere while working under Dr. Simon’s restrictions and would sooner relinquish my contract than cut our productivity, increase our working hours, or turn away patients with significant surgical illnesses. I needed the Minister to state in writing that Arnaldo was authorized to continue his duties in the operating room as formerly. Nothing less than that would be sufficient to allow our work to continue.

It was a tense time, since everything was now on the line and there were no encouraging reports regardless of whom I spoke with. For a week, things only got worse. Dr. Vaz was unable to secure an audience with the Minister, so he tried talking with the Vice Minister. The Vice Minister rebuffed him and repeated his ominous warning that he too was waiting to speak with the Minister and that what he had to say did not bode well for Dr. Vaz or me. My nightly phone calls to Dr. Vaz furthered our friendship but painted an increasingly desperate picture.

For the surgical team, the situation was even more grim. I at least could fall back on the church work for satisfaction. It always needs more attention than I can give it, as does the family. As I braced myself for becoming medically unemployed, I could still rejoice at the prospect of fulfilling many long delayed projects on those two fronts. For the rest of the team, there was nothing to look forward to if the program folded. For the orderlies, there wouldn’t even be employment.

Perhaps the most poignant moment for me came the Sunday after the Vice Minister’s visit. I was preparing for the evangelistic service at the hospital, attended by nearly a hundred patients and family members when I was pierced by the realization that these opportunities might soon end. Never had the hospital at Marrere with its foul latrines and roach infested rooms seemed like such a lovely place to work as during that moment when I saw the rich evangelistic opportunities it afforded slipping away.

My favorite words of scripture are the two that begin Ephesians 2:4. They are the words that form the hinge upon which our eternal destiny turns. After describing the situation every one of us is in until coming to saving faith in Christ – a circumstance infinitely more hopeless than the one we were now in with the Ministry – Paul begins to describe the unbelievable change in the believer’s condition with the words, “But God…”

The account that follows is truly a “But God…” event! The human agent God used in orchestrating it all was Dr. Geelhoed, a specialist in surgical endocrinology and professor of surgery at George Washington University medical school in Washington, D.C. Dr. Geelhoed has been touring southern Africa throughout 1996 as a Fulbright scholar and had come to Mozambique on a visit earlier in the year. During that visit he passed through Nampula with Mozambique’s own surgical endocrinologist, Dr. Ivo Garrido. Since Marrere is the only surgical center in the province that does endocrine surgery, the Provincial Director made sure these two specialists paid us a visit. I presented a comprehensive report of all our thyroid cases, and the visit came off very well. This was in part because Dr. Geelhoed’s interest in southern Africa, like mine, is not purely surgical. He is a Christian from the States and had done short term missionary work in Africa before embarking on his career in academic medicine. He never lost his interest in Africa though, and applied for the Fulbright scholarship in part because it afforded the opportunity to re-live his experiences as a missionary doctor.

Dr. Geelhoed returned for a second brief visit to Mozambique just when our problems arose. As he tells it, he was sitting in the Ministry of Health awaiting an audience with the Minister who wished to thank him officially for services rendered on his first visit when he saw a letter from Dr. Simon suggesting that the surgical program at Marrere be abolished. Having become a personal friend of ours and an enthusiastic promoter of Marrere both in the States and Africa, he was appalled. He postponed his meeting with the Minister in order to draft a strong letter praising the “outstanding program” he had encountered at Marrere, especially extolling the high quality of training evidenced by the excellent work done by Arnaldo. Dr. Vaz was only too happy to translate it all into Portuguese and when his audience with the Minister was re-scheduled several days later he surprised him with a eulogy of our ministry that would bring color to the cheeks of any corpse. His glowing report coupled with his lofty stature amongst officials at the Ministry completely won the day for us. The Minister said Dr. Simon was but a child who did not know what he was about, and that he would be sure to visit our surgical center on his upcoming trip to Nampula.

Following his visit, Dr. Geelhoed immediately called me at home in Nampula. I was amazed to hear from someone I thought had returned to the States months ago, and then dumbfounded as he described God’s providence in our behalf. Dr. Geelhoed’s first words to me were, “You must have some powerful prayers behind you. You’re not going to believe what has just happened.” We do, and I scarcely can!

However, God had only begun to turn the tables. When we received word that the Minister would be in Nampula for one day, 27 August, and that Marrere was to be his first stop, I immediately thought of a patient I had seen in clinic a couple of weeks earlier. How I would have loved to present her to the Minister as an example of why the surgical program at Marrere was vital to northern Mozambique! She had undergone a hysterectomy at the Central Hospital over two years ago and healed with a fistula connecting her bladder directly to her vagina. Urine flowed continuously onto her clothing and bedding and made life miserable for her. She was from one of Nampula’s upper class families so had the means to contract at great expense with the most respected local surgeon to perform corrective surgery. Vessico-vaginal fistulas are among the toughest cases we do here, and not surprisingly, after two more operations the defect persisted. Having given up on getting her problem corrected in Nampula, she flew to Maputo and scheduled a consultation with the leading gynecologist in the country. He treated her with medications and refused to offer her an operation. After a lengthy trial of medical treat­ment which was doomed to failure since the problem can only be corrected surgically, he sent her back to Nampula. For two years she had to wear foul smelling diapers until learning that we corrected fistulas at Marrere. She had been seen by me on 7 August, before we knew of the Minister’s upcoming visit, and I scheduled her operation for next October.

Now I just wished there were some way to call her in, do her operation, and present her to the Minister of Health. However, we didn’t have a clue how to get hold of her. But God knows all things, and exactly eight days before the Minister’s visit who should I find waiting for me on the hospital steps but my fistula patient! For reasons no one can explain, she had decided she did not want to wait until October to have her operation. She packed her bags, came to the hospital, and wanted to be operated on at once. She had even skipped breakfast so she could be done that very day!

This was clearly a turn from God. We immediately escorted her into the operating room, and shortly discovered why the Maputo gynecologist had deemed her an unsuitable surgical candidate. She was terrified of anything surgical, though perhaps she had good reason to be in view of her history. The first item of business was to repeat the exam with a special instrument that would give us a clear view of the fistula. It is an entirely painless procedure but the way the whole team had to pin down each of her limbs to allow me even a brief look at the fistula, you would have thought we were playing rugby on the operating table rather than treating a patient. Then she had to be catheterized, which again necessitated everyone piling on the patient and was carried out amid screams of supposed pain and terror. The spinal injec­tion was no different, and even after anesthesia set in she pleaded to be put to sleep for the operation. She was short but very heavy, and we could not risk sedating her too much as her respirations would already be hampered by her partial paralysis and the great weight of her chest and abdomen that had to be moved with each breath. In the face of such utter terror, I marveled that she came in for her operation at all, let alone two months ahead of schedule. However, while it was hard to explain on a human level, I was sure of the ultimate explanation for why she was now lying on our operating table.

For the same reason, I knew everything was going to turn out perfectly, even if we had the laundry men come in and do the operation. And just as we expected, the procedure went flawlessly. We opened her abdomen, dissected out the inside end of the vagina, then opened her bladder and identified the fistula and ureters. Working from inside and outside the bladder we divided the fistula, closed the defects in three layers, and then put a patch of fatty tissue (of which there was an abundance) between the bladder and the vagina. Now all she had to do was heal.

And heal she did. She did not loose even a drop of urine in the post-op period. The seventh day after surgery we removed her urinary catheter and she began voiding normally for the first time in over two years. The next day the Minister arrived. We could not have timed it better, but that is one of the hallmarks of God’s providence, isn’t it?

His visit was much different from the one earlier in the month with the Vice Minister. The Minister was accompanied by an even larger and more dignified entourage. The surgical team had carefully prepared a thirty minute presentation we hoped would impress the visitors. We covered a bulletin board with pictures of our most remarkable cases. There were pages of handouts, reams of statistics, and live demonstrations. Some of the statistics regarding the team’s productivity were:

  • Over 13,000 surgical consultations in five years.
  • 3002 operations.
  • 120 consultations in one day, on 10 September 1992.
  • 58 operations scheduled in one day, on 14 September 1994.
  • 95 operations performed in one month, in August 1994.
  • 13 operations performed on one day, on 7 August 1996.

This was not the work of a single individual. There are seven others on the team and each functions well beyond the capacity expected of orderlies or nurses. The orderlies assist on operations and handle sterilization of material, while the nurses operate (in the case of Arnaldo), administer anesthesia, make rounds, work up patients, and perform consultations. I had the opportunity to present each of them to the Minister of Health and praise their excellent service.

Which is where the verse at the head of this letter comes in. For these fel­lows, who live in mud huts with dirt floors and grass roofs, being recognized for their diligent, tireless, and invaluable work in the presence of the very Minister himself was the fulfillment of an impossible dream, but one which we have often referred to in daily devotions with a boldness which could only be justified because God Himself speaks of it in His word.

We concluded the report by presenting our fistula patient. By God’s grace, and certainly that is no empty cliche in this instance, it had taken our team only one consultation, one operation, and 12 days to solve a problem that two regional referral hospitals had been unable to resolve after much pain, expense, and lost time. The effect on the Minister was just what we had hoped it would be. After the presentation he invited me to join him and several other guests for dinner that night so we could discuss the surgical center Grace Missions would like to build, and talk more about Arnaldo (another fulfillment of Proverbs 22:29 – thanks to Dr. Simon he is now known not only throughout Nampula but also in the halls of the very Ministry of Health!).

At dinner that night the minister said that he had decided to prepare a document authorizing Arnaldo to operate as long as I accepted full responsibility for his work. He further said he would not only grant Grace Mission’s request to build a private surgical center in Nampula, but would give it his full support at the Ministry level and wanted it to function as a training center not only for surgical technicians but for doctors who wish to become licensed as full-fledged surgeons in Mozambique.

So now we have the support of the Minister of Health, the Provincial Director, Dr. Vaz (chief of surgery in Mozambique and director of the nation’s surgical training program), and the Nampula businessman’s association. Of all the people whose support is needed for Grace Missions to go ahead with this project, the only one we have yet to win over is the governor of Nampula. The businessmen say that will be a mere formality once they speak to him. They have even suggested they would get the President’s endorsement if that were needed.

What a dramatic demonstration this month has been of the sovereign grace of God in directing the affairs of men! From Doctor Simon to the Minister of Health to Dr. Geelhoed from George Washington University school of medicine to Arnaldo and Jeremias and Julia, our fistula patient, God orchestrates every­thing and everyone to the end that His purposes should be accomplished. And for us, that is a wonderful consolation in the hour of trial, especially since it now appears certain that His purpose is to build a Christian surgical center in Nampula that will serve as a witness to the whole of northern Mozambique. If that happens, it will exceed my most far-fetched dreams, but Ephesians 3:20 speaks of a God who is “able to do exceeding abundantly above all that we ask or think, according to the power that worketh in us.” And as the next verse says, “Unto Him be glory in the church by Christ Jesus throughout all ages, world without end, Amen!”