Health for All: The Vanga Story

By Daniel E. Fountain

When Dan Fountain and his wife arrived in the Congo in 1961, the challenges to effective medical missions seemed overwhelming. As the only doctor for a quarter of a million residents of the Vanga Health Zone, and with nothing but a dilapidated mission hospital and an undertrained staff to run it, Dr. Fountain turned to prayer, innovation, and local partnerships to meet the vast needs of his area.

Health for All tells the story of an ever-increasing vision—from curative care to community health, from a barely functioning hospital to a network of successful health services, from a lack of qualified workers to a local residency training program, from biomedical reductionism to whole person care, from cultural stalemate to worldview transformation. Dr. Fountain’s insights into health and wholeness have changed countless lives and communities. Part memoir, part history, part textbook, Health for All is the legacy of a man who patterned his life and labor after that of the Great Physician.

• Language: English
• Publisher: William Carey Library
• Release date: May 30, 2014
• ISBN: 9781645080848

Book preview

INTRODUCTION

Paul Musiti, a well-trained nurse with a graduate diploma, was the administrative director of the Vanga Hospital when my wife and I arrived in 1961 to begin our service there. He was a wise man, a leader among his people, and knew how to manage programs well. I learned much from him during my long years in Africa.

One day in 1961 we were chatting in his office, and he asked me a pointed question.

You missionaries brought the gospel to us, and many of us have become followers of Jesus. We know that you Americans have developed a remarkably prosperous civilization. You have told us it is because, through the centuries, you have incorporated many biblical values into your culture, such as trust, integrity, order, discipline, planning, hard work, and concern for other people … We Africans are poor and remain poor. You missionaries brought the gospel and the church to us. Why did you not teach those values to us? He spoke the truth, and I had no answer to his question.

That question had a strong influence on me as I began my service there. The people of Africa need more than just spiritual knowledge. They need to know and understand the principles God has shown us on how we are to live and find the abundant life Jesus came to show to his followers. They must discover and apply the values we find in the Bible from beginning to end that promote personal and community life. That includes health and not just medical care, and the empowering of people to improve their own way of life and health conditions. How could I incorporate into the medical missions I had come to do the transmission of the values the people needed in order to build a stable and prosperous society?

This book is the story of how I became part of the Vanga community and how God was able to work in us all to enable the Vanga comprehensive health service to develop. It eventually became the model for the national health plan of the Democratic Republic of the Congo (DRC). A paper I wrote about it in 1973 got to the headquarters of the World Health Organization (WHO) in Geneva and became one of the models of primary healthcare for the international health conference in Alma-Ata (now Almaty, Kazakhstan) in 1978. The slogan that came from that conference was Health for all by the year 2000. The Vanga Rural Health Zone achieved health for all in that catchment area by 1985. Now the DRC has more than five hundred health zones functioning on this model and providing primary healthcare for more than half of the population.

The book describes the development of this service, not in chronological sequence but in a thematic form. It is in a narrative that also includes the principles we learned from the Lord as well as from our experience, and how we applied them. Thus the book can be used in many schools for training intercultural community development personnel. Basic principles of health and community development are exemplified through the chapters. There is a heavy emphasis on cultural dynamics, how to develop relationships with the people of another culture on the level of worldview assumptions and values, and how to communicate the assumptions and values that favor health and development. I have written this from our Christian experience, for it is the Christian faith with its biblical assumptions and values, applied by the people, that has enabled this service to become established and sustained.

The first four chapters describe the building of the foundation of the rural health zone and how we achieved accessibility of primary healthcare for everyone according to WHO standards. The next four chapters give an in-depth discussion of cultural examples and the story of how I went through this in the community dialogue that launched the church-based community-focus health development program. The subsequent five chapters describe other service programs that developed. Chapters 14 and 15 discuss issues of management, and the final two chapters deal with the relationships between the Christian faith, health services, and the persons involved in developing and maintaining them.

1

The Vision

A RUDE AWAKENING

Kilamba, a three-year-old boy, lay on a bed in the pediatric ward of the Vanga Evangelical Hospital. A quick glance at his protruding abdomen gave me an immediate diagnosis: a mass of ascaris worms stuck in his small bowel. An intestinal obstruction in a small child, malnourished, somewhat anemic, and already in fluid imbalance—this was not what I wanted to see.

Kilamba lived in the village of Kimbata, a four-hour walk from Vanga, and his mother had brought him to the outpatient clinic that morning. Like most children in villages like Kimbata, he was somewhat undernourished and anemic. In addition, he had a potbelly and often would cry at night because of abdominal pain and cramps. The clinic staff examined him and correctly presumed he had intestinal worms. A stool exam confirmed this with many ascaris eggs found in the specimen. No big deal; every child in rural Congo has intestinal worms of one species or another. They gave him a worm cure—piperazine—and presumed his problem was solved. It wasn’t. Within three hours his cramps increased, he began to vomit, and his abdomen grew progressively bigger. That was when they called me to see him.

A large U-shaped mass was visible in his abdomen, and he was already somewhat dehydrated. I ordered an IV infusion, a nasal-gastric tube, and routine blood work. I decided to wait overnight before making a decision to operate. An obstruction due to worms is not complete—some fluid and gas can work their way through the mass of worms. We could therefore afford to temporize for a few hours. I desperately hoped that somehow Kilamba would begin to pass the worms during the night and so avoid a major operation that he might not survive. Our only general anesthesia was open-drop ether on a face mask, and we had no way to measure blood electrolytes. The surgical risk was therefore quite high. I instructed the staff to go home and pray that the worms would pass, and I went home and did the same. As I prayed I felt an inner assurance that God would indeed heal him if I laid my hands on his belly and prayed for his healing. As I assured the Lord I would do that, the second part of the message came—Make sure you have a scalpel in your hand when you lay it on his abdomen. God was saying, I got you trained in surgery. Don’t ask me to do your work for you. You do your work, and I will be with you to complete it.

Early the next morning, finding the mass unchanged, we took Kilamba to the surgical theater. The operating room was packed with staff wanting to see what would happen, for this was indeed a big deal. When I opened the abdomen of this little boy, I found a large loop of small intestine ballooned with worms—big ones. A tiny hole in the bowel allowed me to pull out the worms one by one. As I removed them, the onlookers counted. When the last worm was removed (alive and moving), the final count was 497. I closed the small hole in the bowel and then the abdominal incision. We sent him to the ward, and God was faithful to his promise to heal him. Within a week Kilamba returned home, proud as punch of his abdominal incision. This was a major surgical triumph; we were delighted and so was his mother. God was too, I believe.

Four months later Kilamba stood in front of me again in the outpatient department. I looked at him, looked at his distended abdomen, recognized the incision, saw the stool exam report showing ascaris worms, and gasped. Another bellyful of worms! A thundering question came to mind instantly—what on earth had I done for the health of this cute little boy? The answer was clear—absolutely nothing! Unless we bring about changes in health-related understanding, behavior, and conditions in communities, we can have minimal impact in improving the lives of people.

THE PROBLEM OF MEDICAL CARE ALONE

My wife, Miriam, and I had come to the Congo to heal sick people, but not to heal the same ones over and over again. We had come to establish a health service, but all we had was a medical service. Our hospital could be likened to a body and fender shop, repairing the damage of wounded people but doing nothing to prevent those wounds or illnesses or health problems. Our vision was too narrow and our approach was too constricted. We had to make major paradigm changes if we were to be effective as a physician and a nurse. We had to learn how to go beyond just healing sick persons to promoting and celebrating health.

A HEALTH SERVICE

What is a health service? A health service is based on a paradigm that focuses on health and on helping individuals and communities to be healthy. This paradigm has four operational objectives:

1. To promote the health of individuals and communities.

2. To restore health and wholeness to individuals and communities that are ill.

3. To train and empower healthcare personnel on all levels.

4. To make effective healthcare available to all individuals and communities geographically, economically, and culturally.

THE PARADIGM OF HEALTH

The health paradigm rests on five assumptions:

1. Life is unified although multidimensional. It is not compartmentalized into separate parts. Health, well-being, and transformational development involve individuals and communities. They require initiatives that are physical, social, economic, political, environmental, and spiritual. We must integrate all of these services together.

2. Diseases come from many sources, not just physical ones. Many illnesses come from a combination of physical, emotional, social, economic, cultural, and even spiritual causes all interacting together.

3. Health is an individual and a community issue, not just a medical program. As a physician, I can make no one healthy, nor can I make a community healthy. I must work both with individuals and communities, however, to provide information they need, motivation to stimulate them, and certain resources beyond what they have themselves. The chief resources, however, must come from them—wisdom, the knowledge of their own people and culture, and the skills and abilities God has given to them.

4. Health providers need to be cognizant of the whole picture of the life of a sick person and of the community and nation. Any given provider will, of necessity, focus on only a small area of illness, because with the accumulation of knowledge and technology, specialization is necessary. Nevertheless, specialists must be aware of the full dimensions of health and illness and be prepared to work as a team with other providers to promote health and healing in all dimensions.

5. Health personnel must be health promoters. We must multiply our knowledge and skills through training others, sharing the vision of health and wholeness with individuals and communities, and participating as team members with all who are working toward a healthier world.

MEDICAL MISSIONS

I am writing this book from the perspective of many years in the practice of intercultural healthcare. This has been my calling and my experience for more than half a century. Medical missions has a history of almost two centuries, and from the beginning has had a broader and deeper vision of healthcare than has the biomedical model from which it has come. It has pioneered healthcare in many parts of the world where medical services had not previously penetrated.

Dr. Peter Parker, an American ophthalmologist and missionary, went to China in 1834 and gained credibility among Chinese leaders for medicine and Christian missions by establishing an effective eye care service. This included the successful treatment of a serious eye disease in the nephew of the emperor of China. This deeply impressed the emperor and enabled missions and Christian physicians to begin medical services in China.

In Africa, the earliest missionary was a physician, Dr. David Livingstone. He brought simple medical care to many people and made the Western world aware of the immense health needs of that continent.

Mission medical services also penetrated into many areas of India where no modern medical services yet existed. It was a missionary surgeon working in North India, Dr. Carl Taylor, who was the first missionary allowed into the Kingdom of Nepal. The King of Nepal was aware of the health needs of his people and invited Dr. Taylor to come and make a survey. Dr. Carl Frederichs then followed to set up a mission hospital. From the beginning much of the mission work in Nepal has centered on health and community development.

FOUR PHASES OF MEDICAL MISSIONS

Medical missions has evolved through four phases:¹

Doing Phase

Through much of the nineteenth century, medical missions was in the doing phase. Missionary doctors went out to do medicine; nurses went out to do nursing. Medical missionaries established hospitals and clinics, often in remote places where logistic support structures were minimal. Medical missions pioneered the development of leprosariums, and missionary physicians carried out much of the basic research and innovations on leprosy care.

Training Phase

Around the beginning of the twentieth century medical missions entered the second, or training, phase. Missionary doctors and nurses realized that the health needs of the people they served far outstripped their abilities to meet them. They created nursing schools in many countries in Asia and Africa patterned on the Florence Nightingale model—compassionate care of sick people in hospitals and clinics. In India, medical missions pioneered two medical schools—Vellore and Ludhiana—and began training Indian Christian women and men as physicians. Presbyterian medical missionaries opened a medical school in Korea. Mission-operated nursing schools continue to provide a large percentage of the nurses in India, in the Philippines, and in many African countries.

Empowering Phase

By the 1950s, the number of national Christian nurses and physicians had grown in numerous countries, and the churches in these host countries were becoming more involved in the operation of the medical facilities associated with them. Medical missions then gradually shifted into the third stage, that of the empowerment of national churches and their medical staff. Missionary doctors and nurses did not stop doing medicine and nursing, nor training health personnel, but now they began working alongside their host-country colleagues, mentoring them to prepare them to assume greater responsibilities for health programs among their own people. This also involved developing residency training programs in family medicine, designed to enable young physicians to practice good medicine, promote health, and train subsequent generations of health personnel.

Partnership Phase

The empowerment phase led quite naturally into the current phase of partnership. Christian health personnel from the Global North are now becoming integrated into health teams of host-country churches. There is the mutual sharing of resources, each partner contributing what it can provide in material, cultural, and spiritual resources. This promotes mutual learning and the cooperative building of multinational and multiethnic health services. Medical missions as such has now given way to Christian health programs that are often international in character and, in many places, are growing in their impact on health, development, and cultural transformation.

A BIBLICALLY WHOLISTIC APPROACH TO HEALTH

Christian health programs have been leaders in healthcare in many Asian and African countries and in Latin America. They target disenfranchised people, those too poor to afford modern medical care and those outside the reach of government or private health services. The vision of Christian health programs has embraced the values of sacrificial service and compassionate care modeled by Jesus, the Great Physician of the first century, operating on the assumption that the care of sick persons is of great value, with healing and restoration to wholeness as the desired end.

Christian health programs reject the exclusion of spirituality by the biomedical model, believing that man is a spiritual being and has an eternal destiny, the nature of which he is free to choose. Consequently, evangelism has been part of these programs from the beginning. This is based on the assumption that all people need to hear of the hope of eternal life with God through a personal relationship with Jesus Christ. Recently the intimate link between this hope and physical health has been recognized, along with the major influence that feelings and emotions have on physical illness and healing. Christian health programs have pioneered a team approach to caring for the whole person.

A CULTURAL PROBLEM OF REDUCTIONISM

In ancient cultures, and still in many cultures today, illness is interpreted as a spiritual and social event. Something has gone wrong in one’s relationships with the living, the spirits of the ancestors, or the world of spirit. Healing requires restoration of those relationships and is therefore a religious process involving priests, temples, shamans, rituals, and sacrifices.

With the rise of Western science, a major cultural shift occurred. We in North America and Europe have developed the biomedical model of medicine, which reduces the understanding of illness to the physical dimension of life. We assume that every disease has a physical cause and that the treatment of all diseases is primarily a physical or technological treatment. Spiritual issues are assumed to be of little or no importance. Social disruptions are often ignored or else relegated to other service providers. Modern medicine focuses on curing diseases rather than on healing sick persons. Diagnosis has shifted from social and spiritual perceptions to physical technology. Faith and science have gone separate ways, often with competition or even antagonism between religion and medicine. Religious departments, as chaplaincies, do exist in many medical institutions, but they function as ancillary services and are seldom integrated with medical care.

Government health ministries have established medical services and training schools in all countries. These are patterned almost entirely on the biomedical model of Western medicine. These medical services do not provide healthcare, but rather sickness care. The service component has become an industry, and altruism has been replaced by commerce—the bottom line.

PROBLEMS IN MEDICAL MISSIONS

Cultural Insensitivity

The development of medical missions has had significant problems and failures. One serious failure was the insufficient attempt to make modern medicine culturally accessible to people of diverse cultures. Medical care came to people who had traditional concepts of illness and healing, but we from the West failed to analyze the interface between the two or to explain medicine and health across cultural differences. Missionaries from the Western rationalistic worldview explain health and hygiene in scientific terms that traditional peoples cannot understand. As a result, competition between medical and traditional approaches to healing continues in many places, with vast numbers of people refusing to avail themselves of modern medical care because they fail to understand it. They maintain their trust in their own familiar healing traditions. The gap between modern medicine and traditional healing practices has not been effectively bridged. Attempts to integrate the strengths of both have been insufficient.

Paternalism

Paternalism characterized the early development of medical missions and unfortunately lingers to this day in some situations. Modern medicine has developed within the rationalistic culture of the Global North. Consequently, Western-trained health professionals, even Asian and African ones, assume that medicine has answers to the health problems of all people and that traditional people have no wisdom related to health conditions. Nothing could be further from the truth.

Western Domination

Another serious issue is the assumption that Western-trained health professionals must be in full control of medical institutions. They must retain in their hands the management of all aspects of medical care. Underlying this assumption is arrogance and an unwillingness to learn the wisdom and values of the people they are trying to serve. Furthermore, many Western health providers do not study the cultural dynamics of management and how to transfer necessary principles and values to people of different