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.

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.

What should characterize public health done by Christians?

Public health skills are powerful tools to promote flourishing of communities; they complement medical care of individuals.  Christians also want to promote human flourishing, since this demonstrates the goodness of God.  What will characterize public health done by Christians?

Some of the ancients were inclined to treat disease and plagues in terms of supernatural forces and magic, shamanism and religious practices. The Hebrews stressed regulation of personal and community hygiene, isolation of lepers and other ‘unclean conditions,’ and family and personal sexual purity; God gave to Moses commands related to a weekly day of rest, limits on slavery and oppression, sanitation and food regulations.  The children of Israel gave to the world the teaching concerning human dignity since all are made in the image of God.

Modern public health is a noble sphere of human endeavor, whether done by Christians, Muslims or Secular modernists. Good public health practice should be characterized not only by good science but love for humankind. Christians are especially motivated by the value of human beings, as well as God’s command to love the Lord our God with all our heart, and love our neighbor as ourselves. We glorify God by seeking His best for our fellow human beings.

At the same time, modern public health – Jenner and vaccination, Snow on cholera, germ theory, bacteriologic revolution, hospital reform, immunology, the development of epidemiology – has grown up as part of the modern scientific revolution and out of Enlightenment thinking.  It is often characterized by a ‘split’ of sacred and secular, and a peculiar perspective that things ‘scientific’ define reality whereas things of God are confined to personal and private belief. I believe this is an inadequate foundation for public health as it tends to relegate ethical and moral matters to a private and subjective world.

As Christians we have much we can learn from our public health teachers, and much to give in order to alleviate the suffering of this world.  But ultimately our motivation for doing public health is to demonstrate the character of Jesus Christ to the world; we cannot bring utopia to this world but we can point to a Savior who cares about men and women – body and spirit. He is the Savior who not only frees us from our sinful selves but also frees us for His purposes in a world which He has made and is in the process of re-creating.

As a Christian epidemiologist, I will use the techniques of case control studies, disease surveillance and risk identification just the same as anyone else. The tools are the same, whatever our faith orientation. Our desired outcome – disease prevention and health promotion – will be the same; public health professionals seek the best for others.  Christian public health is not just public health done by Christians; it becomes activities, programs, policy and advocacy informed by God’s Word – which commands us to ‘love justice, seek mercy, and walk humbly with.. God.” (Micah 6:8)

A Christian perspective on public health and human flourishing will be informed not only by material success, but also by an understanding of the darker forces we face, including suffering and death. It will seek to address these matters with courage and meaning. A Christian perspective on public health can deal with life well because of the hope God offers in His promises in both life and death. The cross of Jesus Christ has won the victory of sin, darkness and rebellion in order to usher in life here and eternally.

Ultimately health is not an achievement of man but a blessing of God. And He is working in the world to bless the world through His Son Jesus Christ, who gave His own life for the ultimate in public health – salvation from sin, rescue from darkness and oppression, and the freedom of a life of love and grace.

A new era in Roman healthcare

We take for granted that compassion is a natural response to the suffering of those who are ill. But compassion was not well-developed as a virtue in Roman culture.  Rome had not developed a culture of compassion; “mercy was discouraged, as it only helped those too weak to contribute to society.” Family members may come to one’s aid, and the wealthy could afford physicians, but “the common folk were often left to rely on folk healers and sellers of herbs, amulets and quack remedies.” *

“If a father decided that the family couldn’t afford another child, that child would be abandoned to the steps of a temple or in the public square. Female infants were exposed much more often than males.” These attitudes and practices are still with us today.  In India and China the practice of aborting female offspring is distressingly common.  In many parts of the world the handicapped are treated with disdain or neglect.

“The classic world possessed no religious or philosophical basis for the concept of the divine dignity of human persons, and without such support, the right to live was granted or withheld by family or society almost at a whim.”

What made the difference between attitudes then and now?  At least in many parts of the world today, human rights and dignity are considered absolutely fundamental (and they are!). Where then did these more ‘progressive’ beliefs come from?  The new ‘era’ in Roman healthcare came from the least likely place: from a new, small and persecuted culture which penetrated the classic Roman world: the culture of the Christians.

Despite a series of ten devastating persecutions, beginning with Nero in AD 64, Christians “carried on an active ministry of philanthropy which included the care of the sick. Far from the stereotype of shriveled ascetics who hated the body, early Christians valued the body and the medical arts necessary to heal it as good gifts from God.”

“James defines “religion that is pure and undefiled before God” in part as caring for ‘orphans and widows’ (James 1:27) — biblical shorthand for all those without protectors and in need. Christian theology thus birthed a personal and corporate charity which surpassing any previously known. Church leadership encouraged all Christians to visit the sick and help the poor, and each congregation also established an organized ministry of mercy.”

How different this is from our practices today!  How often we are concerned about ourselves without hearing the Lord’s commands to love God with all our heart and our neighbors as ourselves.

“A devastating epidemic began in 250 AD and spread across northern Africa to the Western Empire.  It lasted 15 to 20 years, and at one point in Rome 5,000 people died in one day. Beyond offering supplications to the gods for relief, public officials did nothing to prevent the spread of the disease, treat the sick, or bury the dead. This is not surprising, since the pagans believed that nothing effective could be done in a time of plague other than appeasing the gods.”  However in places like Carthage, north Africa, where the plague swept in with force, the Bishop Cyprian  “encouraged Christians to donate funds and volunteer their service for relief efforts, making no distinction between believers and pagans.”  They continued these organized emergency relief efforts for five years.

“The ministry of medical care in early Christianity began as a church-based diaconal, not a professional, ministry.  It was provided by unskilled, ordinary people with no medical training. Yet the church created in the first two centuries of its existence the only organization in the Roman world that systematically cared for its destitute sick.”

This is not a secret we want to keep from believers around the world today.  From Syria to Thailand, believers are caring for those who are marginalized and ill.  But sometimes I fear we forget our history, and we forget God’s command to love our neighbor.  Medical missions are a wonderful calling and ministry. But as we go about it we must not ‘overly professionalize’ ministry to those who are sick and brokenhearted. Unskilled believers ushered in a new era of healthcare in the Roman empire.  We have the opportunity to do the same among multiplied countries around the world, demonstrating goodness and grace of God, and the dignity of men and women created in His image.  This can be done only as professionals work together with non-medical professionals to care for the needs around them, especially those who are least able to help themselves.

Despite the cost, let’s help usher in a new era of healthcare around the world.

*Quotations are from “Christian History, Healthcare and Hospitals in the mission of the church,” Issue 101, pages 6-12

Taking it in steps?

A missionary doctor, nurse or health provider in his or her first term is all enthusiasm. After all, he or she may think, “After all that preparation, let’s get on with the real work!”

But those first few years show how much more there is to learn! First there is the adjustment to the new sights and sounds, then a new set of co-workers, then a new job, and of course there is langauge learning!  We want to provide excellent medical care but face the obstacles that often exist in resource-poor settings.

On top of these things, in those first years we may also be working on:

  • issues of marriage and singleness
  • growing a family
  • integrating spiritual and physical ministry into practice
  • understanding how our role fits with the vision and strategy of mission and church
  • doing things outside of his or her training, such as leading a team or projects
  • conflict and team formation
  • identity issues (“who am I really?”)

During this intense time of learning and growing, sometimes I am asked for advice on getting futher training: should I do an MPH degree?  get tropical medicine? learn more about management and leadership?

Looking back over my own 30 years with SIM in medical missions, I think I tried to do too much too early. So my suggestion is this: take a longer view and then break it up into steps.

The complexity of the task means that if we try too much too soon, we won’t do anything well. So in the early years it may be best to focus on the basics: our relationships, especially marriage/singleness/family; language learning; and practicing what we have been trained to do.

Then it will become clear what is needed for later stages.  Not everyone needs to go on and do a public health degree.  Not everyone needs to go to seminary.  Not everyone needs to become skilled in management.  But everyone should grow in their understading of their gifts and abilities, and over time, take on new challenges. Everyone should grow in grace and the knowledge of our Lord Jesus Christ.

“For we are His workmanship, created in Christ Jesus for good works, which God prepared beforehand that we should walk in them.” (Eph 2:10).

The process of discovering those good works prepared for us by God is a journey.

Let’s take it one step at a time.