“We all sat at the same table.”

 

When resources are scarce and medical professionals are few, one gets overwhelmed with the physical needs of patients needing care.  Emotional, spiritual and community care seem like a luxury.  Yet the challenge is how to make a long range impact in these communities.  Here is an example from the Hopkins Medicine journal which shows how one group of professionals brought patients and community to ‘the same table’ – and thus began to discuss deeper issues.

After trying to engage women in breast cancer screening through a local church, these medical professionals felt like failures; only two women signed up. Lesson 1. Short term outreach which does not involve the community from the start has limited long term impact.

Despite their disappointment, they asked for feedback from the church, and were invited to a monthly meeting. “Someone stood up and said, ‘Doc, no one wants to be a patient.'” Being a patient was perceived as a burden, and the outreach was thus an invitation to become a burden.  “It was a hard lesson,” the author concluded, “that picking up medical services and dropping into a neighborhood without taking into account the communities priorities, stuggles, or having trust — that’s a formula for failure.”  Lesson 2. Our best intentions may be perceived very differently than we intend, and we must be humble enough to receive feedback from the community’s perspective.  (Think about short term medical missions; how often do we proceed with our own agenda?)

The author and his colleagues modified their approach to emphasize “knowing the science, knowing the patient and knowing the community.”  They launched an organization called “Medicine for the Greater Good,” to engage the socioeconomic determinants of health. Through this organization they created community partnershps which included not only the patients at risk but churches, schools, City Hall and health department — all sitting at the same table.  “We discovered that somewhere along our long journey as doctors, we had come to viewhealth as synonymous with medicine: prescriptions, research, guidelines. But for the community, health was more than feeling well.  Health is jobs. Health is providing for one’s family. Health is going to church and going to the park. Health is a sense of purpose.”   Lesson 3. One of the biggest obstacles to long term community transformation is our own misunderstanding of health!

Read the results of their discussions and the fulfillment they began to find.  How do we translate these lessons into health ministry motivated by the love of God and the good news of salvation through Jesus?

  1. Link short term outreach to long term engagement with the community, not an approach driven by one-on-one patient care.  Love demands that we think from both perspectives.
  2. Spend time with the community, not just with the patients that come from the community. This means actually getting out to know community members in their own homes, neighborhoods, churches and places of worship. It means getting meaningful feedback about how we are perceived. Our best intentions may not communicate the love we intend to show.
  3. We must change our minds about health. Health is not just meeting physical needs – but transforming community.  Most of the determinants of health are matters which the good news of Jesus addresses  — such as anger, sexual immorality, greed, guilt and shame.  Our role as health providers is not only to provide relief where we can, but to journey with our patients and community as Jesus builds His kingdom in their midst.  Jesus provides forgiveness of sin and relief from of the shackles that often lead to poverty and ill health.   The good news of the gospel provides meaning even when suffering cannot be fully alleviated.  As Christian health providers let’s not just be caught up in our useful activities, but also learn to sit at that table with the communities in which we serve.

 

Want to change the world? Invest in institutions

SIM’s first Asian medical missionary, Dr. Andrew Ng, served for years at Galmi hospital in Niger, and later provided leadership for SIM from Asia. He always had a youthful vision for how Jesus is shaping the world, and a special love for Jesus’ work in medical missions.  And while he just went home to be with his Lord, Andrew left me with many lessons. One of those lessons was about institutions. “Think about Mother Theresa,” he would say. He could see that she and her institution had a world-wide impact.

Here is how Wikipedia defines institution: “An institution is social structure in which people cooperate and which influences the behavior of people and the way they live. An institution has a purpose. Institutions are permanent, which means that they do not end when one person is gone. An institution has rules and can enforce rules of human behavior.”

Are you looking for lasting (even permanent) change? Try building up institutions! Hospitals of course are one type of institution. Let’s not just ‘do’ our medical ministry, but ‘leave’ hospitals where people love Jesus and continue to serve those broken in soul and body.  That means that part of our Christian effort is to invest in local people in order to build leadership and good governance, with a heart for this ongoing mission of Jesus!

Gordon Smith makes an excellent case for institutions in his Gospel Coalition article with this title:  Want to change the world? Invest in institutions.

But hospitals are not the only kind of health institutions. Hospitals and modern healthcare are important places to care for the brokenhearted. [The good Samaritan needed a place to care for the wounds of his new friend, and we have much in the 21st century to offer to relieve physical suffering.] But there are other kinds of institutions — some of which operate outside of bricks and mortar — social structures or organizations with governance and leadership that allows people to work together for good.  For example, an institution with a mission to:

  • do excellent hospice care
  • enable children to have access to clean water, sanitation, nutrition
  • build communities of individuals who will counter the poor health effects of local superstitions and beliefs that are tied to poor health
  • do good public health education
  • come alongside others (e.g. local government or community) in order to enhance response to disease outbreaks (epidemiology), promoting disease control or good local health systems
  • enable local churches to see the opportunites around them to be good neighbors by investing in critical needs such as handicapped ministries, HIV and AIDS ministries and the like
  • the list is almost endless

As Gordon Smith points out, we have a tendency to suspect anything with structure and authority. But rightly developed, institutions remain a key to healing our world.  Let’s not just plant churches, but institutions that flow out of the work of those churches. Thank you, Dr. Andrew.

Listen up!

A new initiative at my alma mater, Johns Hopkins, is breaking ground with a ancient approach; it’s called listening to the patient! The essence of healing from a Christian point of view is compassion.  Compassion depends on trusting relationships. Relationships are built on person-to-person interaction in a caring environment.  The best care involves listening well to patients!

I will never forget one of my mentors, Dr. Phil Tumulty, who was a master clinician and diagnostician at Hopkins. He (and many others) stressed that the goal was not just caring for the disease but the patient. I have been privileged to have learned from teachers who put whole-person medicine in practice.  Yet when the number of patients and the severity of illness becomes overwhelming — as it often does serving abroad in limited resource settings — how do we keep a whole person approach?  How do we keep love-in-action in practice not just in theory?

One innovation is coming again from Johns Hopkins. This article describes the Aliki Initiative, which trains young doctors in the old practice of getting to know patients as people.  During Aliki rotations, residents are trained to write notes that begin with social histories, not just symptoms, and also to make structured follow up calls to primary providers and even visit patient homes after they are discharged.  Wow!  They are beginning to see their patients “much more in human terms, because (they) are more than the sum of their symptoms and lab results.”

“Among other things, this has meant making time for face-to-face conversations with patients, and resisiting the tide of technological distraction and financial pressures to move patients  through the system quickly.

“‘Part of the challenge is that we’ve inherited a training model that, for understandable reasons, focuses on acute episodes of care,’ says (Professor) Ziegelstein.  ‘And if doctors are time pressured, they’ll often assume that they just need to know the bare minimum of medical ‘facts’ to get the patient through that acute episode of care. But that’s not correct. If you slow down and take the time ot get to know the patient as a person, you’ll make more accurate diagnoses, provide better treatment choices and achieve better patient satisfaction.  In the long run I’m confident that approach actually saves time.'”

This initiative has been in place since 2007; one of the early participants says, “Today, I work with diabetes patients, and I’d say that 75% of diabetes care is not really medical.. It’s addressing the psychological, social, and economic factors that influence how patients manage their diabetes at home.”

If this is true in the USA, where there is abundance of good health information available, how much more true is it in northern Nigeria, where women are hidden from the community when they leak urine after vesico-vaginal fistula develops from prolonged labor and inadequate (or no) obstetric services or trained midwife?  Social, economic and psychological factors dominate. Shame distorts her perception of herself (and her community’s perception) and keeps her from knowing she is made in the image of God. This is just one small example, but time and again the medical diagnosis and cure are only a small part of compassionate care.

As Christian healthcare providers in mission, who want to care for people the way Jesus does, we must spend the time to converse with patients. This means building teams that address the various aspects of illness — many of which are not strictly “medical.”  Our “medical” teams must strive to be “healthcare” teams, aiming not only at good clinical care but compassionate care for the whole person.

All of us, from technical doctors skilled in modern medicine, to a Nigerian grandma who helps fistula patients integrate back into community, can learn from the ancient art of conversation.  Proverbs says it this way: “A merry heart is good medicine, but a broken spirit dries up the bones.”

Love in action

In SIM we think a lot about how to integrate faith and good deeds. In our Western mindset these are often separate.

One of our missionaries returned home this week and told us that in her country, Christian medical doctors put “faith” and “work” in separate categories.  So it is difficult for them to imagine how to keep them together.

Jesus healed people physically but also ministered to their souls. He knew when to show love and he knew when to speak the words of God to people.  The ministered to the whole man; there was no separation of faith and work.

One unifying theme that runs through all of Jesus life and ministry is love. John tells us that “God is love, and the one who abides in love abides in God.”  Jesus life was motivated by the love of God and love for people. Ultimately His death the cross was the supreme evidence of that love — rescuing us from eternal suffering for sin, and also restoring us to right relationships with God and others. The cross integrates faith and work.

My missionary friend invited another experienced visiting missionary doctor to a lunch meeting where he was asked by younger Christian doctors, “how can you imagine us bringing faith into the chaos of this urban hospital?”

“Remember those patients we saw lying on the floor this morning?” he asked.

“Yes,” they replied.

“Do you think any of them might appreciate prayer?”

“Well, yes,” they replied again.

“How can we find a way, in your cultural context, to love them enough that they would might invite you to pray for them?”

It was the beginning of a journey to bridge that gap between ‘faith’ and ‘work.’  Or more precisely, it was a call to really look into the eyes of individual patients and families and see them as made in the image of God, not just as people with physical needs.

Jesus leads us to do this because of His love for people. He wants them to know love, since it powerfully communicates who He is, and also opens up opportunities to know Him though words that also come from Him.

 

Sustainable church hospitals

A little publication in 1998 surveyed 43 church-related mission hospitals to identify criteria for sustainability.  They identified nine critical success factors in the process:

  1. Vision/mission/objectives. These hospitals had a Christ-centered vision that had been translated into ‘do-able’ mission statements and behavioral objectives to guide board and staff members at all levels in their day to day work. They were actively revisited at induction training sessions, retreats and other meetings.
  2. Visionary governance. There was appropriate representation of various stakeholders, availability of the range of expertise needed, and availability of the experience required to set up policy guidelines to help the institution in business dealings, etc.
  3. Dynamic technical and managerial leadership. Careful selection of managers and supervisors was reinforced by training, nurtured by prayer, and tested on a continuing basis by application at work. The board showed active interest and demanded accountability at reasonable and regular intervals. These leaders, in their daily interaction with people at all levels and all classes of society, demonstrated commitment to Christian values and determination to live them in words and actions. (Hurrah!)
  4. Reputation for quality of care. These hospitals had a long standing reputation for excellent care in their particular areas of expertise. In many cases this reputation was built by missionary doctors and related staff many decades ago but had been maintained by successors, and continues to serve as a magnet and beacon for patients.  This boosted outpatient visits to an optimum of about 150 per day and filled beds to at least 60 percent capacity; this in itself appears to enhance survival.
  5. Adequate quantity, quality and stability of staff.  These hospitals had adequate numbers of well-trained staff, especially in the strongest specialties. This generated patient confidence. Innovative strategies to reward and retain staff appear very important. Ensuring local access to quality education for staff children was also vital.
  6. Solid financing and financial administration. Key characteristics of the ‘successful’ hospitals were the capacity to generate good revenue, atract local funds and external donations and grants, disburse them wisely, and account for them consistently with generally accepted financial practices. This earned them confidence with stakeholders, patients, governments and donors.
  7. Viable location. Some were in urban areas and able to have clientele who earned money, and others were in rural areas where local people lived near active markets, making incomes reasonable to sustain the hospitals and still serve those who were not able to pay.
  8. Church commitment to health ministry. Possibilities of sustainability were greatly enhanced in situations where churches had inherited hospitals from missionaries but had made firm commitments to to operate them, drawn up clear policies and made it a priority to provide for them financially and materially. Such churches expected to be net contributors to the hospitals, seeing them as part of their Christian outreach or mission. Churches which viewed ‘their’ hospitals as a source of income, taking money out of them whenever possible, tended to be less successful.
  9. Government policies conducive toward private providers. Sustainability was improved when governments made provision for selected para-pubic institutions such as church hospitals to be integrated into the national health network of services, while leaving the churches free to make their own capital development and administrative policies. In these situations, the governments made substantial recurrent-cost contributions to the hospitals concerned, thereby decreasing their running costs and making them more viable.

In planning for successful handover from foreign (or mission) ownership to local, these success criteria can give us a helpful roadmap. Although one may not be able to do much about changing the location of a hospital, plans can develop leadership for many other aspects, such as:

  • Maintaining a Christ-centered vision for ministry
  • Careful attention and planning for good governance
  • Development of leadership both on the technical managerial side as well as the clinical side of services
  • Planning for staff development, including attention to all of life (relational, spiritual and family — even education of children!)
  • Solid financial systems and accountability
  • Developing church leadership which knows Scripture well and can embrace ministry of Word and deed, without neglecting either one. (For centuries the church has been active in giving sacrifically to serve the poor).
  • Advocating with government on policy or larger country-wide issues, especially when it comes to caring for the marginalized and brokenhearted — see Isaiah 61:1)

Community based approaches to primary health care

When I studied international and community health at Johns Hopkins in 1977, primary health care was a new emphasis. Our dean, Dr. Carl Taylor led a department full of passion about reducing illness and promoting health through primary care. But the amount of data about this approach was limited. Like many others, I found that the dream was charming, but not so easily implemented when I went to Ethiopia.

So I was encouraged to hear that now there are over 700 studies in the medical literature which support community based primary health care. Dr. Henry Perry and others at Johns Hopkins have published their findings in the Journal of Global Health here.

The evidence supports CBPHC as an important component of a comprehensively-designed maternal and child health program, not just for the direct effects on maternal and child morbidity and mortality, but because of its contribution to appropriate usage of hospital and clinic facilities. In other words, we need a balance of curative, preventative and promotive.  The evidence is clear.

Here are some aspects of CBPHC:

  • Engagement of women’s groups
  • Innovation like puppet shows
  • Paid and unpaid local workers and volunteers
  • Strengthening the staff of peripheral health centers
  • Using both medical professionals and non-professionals in complementary ways
  • Regular home visits
  • Community based case management
  • Mobile teams

Dr. Perry points out that belief in curative medicine is very powerful; sometimes we are mesmerized by technology and curative care. While they have a very important place, we also know that a large percentage of illness can be mitigated, prevented or treated by non-medical means. We want to embrace good clinical care, of course, but balance this with sustained and intentional efforts to impact communities in broader, more ‘non-technical’ ways. CBPHC may not be technologically sophisticated, yet it can be powerful.

In terms of social justice, Perry points out the CBPHC can have a ‘pro-equity’ effect, avoiding the potential barriers to health care that institutions by themselves can have.

As we make disciples in our healthcare missions, let us remember to raise up both medical professionals and non-professionals, staff who work in institutions as well as those who work in communities.  With needs pressing in around us, we must keep hospitals functioning well yet not consume all of our resources on them — but balance clinical care (tertiary and secondary care) with community based primary health care. We need not only doctors, but social workers, health promoters, and grandmothers who are willing to make the sacrifice to love and invest in communities in order to bring healing to the brokenhearted and hope to those suffering around us.

If we are outsiders to a culture (expats or missionaries) we shouldn’t be naive about the difficulty of such an approach. It often touches on deeply held values, dreams, and cultural approaches which are distorted by our own rebellion from God and the ways of His kingdom. But as we love individuals and learn to serve side-by-side in humility with local people, we can discover how great is our Lord Jesus and enable many to find fullness of life in Him.

Mastery And Mystery

Scott spoke to us at the annual Mental Health and Missions conference in Indiana last month. As health professionals we live in the tension between mastery and mystery, and he helps us live there with his story of grace.

Tending Scattered Wool

Mastery
We seek competency and proficiency in many areas of our lives. That is good and proper stewardship of what God has graced us with in life. As caregivers, it behooves us to provide as excellent of care as we can.

We feel most comfortable discussing and pursuing mastery. Mystery, though, is another reality IMG_0785.JPGaltogether…

Mystery
Its the mysteries in life that undo us.

Mysteries are the life circumstances in which we often feel stuck, confused, and undone. We cry out to God for relief and nothing seems to change. Even the Apostle Paul experienced God saying “no” to him when he cried out for help (see 2 Corinthians 12 for example).

Tolerance for Mystery
God seeks to grow us in our tolerance for mystery. As we grow in tolerance for mystery, we actually become more competent in our mastery. However,  we often, sometimes unknowingly, ignore and hide the broken places…

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