This is a tale of two vehicles. The rugged Land Rover dipped and jolted: the track had not been cut decisively through the bush with its twined undergrowth because few vehicles ever went that way.
The track was for people. The dry season was at its driest and there was dust everywhere: black hair had become brown and clothes had a subtle change of colour. The sun was high so that we stuck to our seats till we reached the village. It had one tiny booth, which was its shop - salt, candles, cigarettes, soap, a kerosene lamp (there was no electricity), tins of fish and a few other unlikely things.
We had come with the hospice visiting team to see a patient; she was already the mother of seven children and now she was in the last days of her eighth pregnancy. But she had cancer of the breast: although she had had a mastectomy, secondaries had been found and so we feared the worst. Our fears were confirmed but she was fit enough to come with us back to the teaching hospital where she had been cared for before.
When we went into her house, cheerful and lively children, wearing miserably poor clothes, pushed and shoved and laughed: no men were to be seen - they were all drinking heavily at a table in another part of the village. They had a very potent home brew. Two, needing each other for support, bothered to come to see who the strangers might be.
When we left, our patient brought her second daughter while the eldest stayed to look after the smaller children. She was delivered of a fine male child, but within four weeks both mother and baby had died: she just became another number in the cold statistics of life expectancy and of infant mortality in a poor country.
Now the second vehicle. The polished Range Rover carried international administrators, cocooned by its slick air conditioning from the bustle of the capital city, with its frenzied noise and sweat. They had just arrived after an easy journey in spacious seats and were staying in one of the big down town international hotels, the preserve of people like them. Their brief mission was to ensure that the poverty reduction strategy of the country was acceptable, a rigid condition before any more development assistance could be allowed.
Conditions and their chilling derivative - conditionality - must not repeat the mistakes of the earlier structural adjustment programmes.[1] The reduction of poverty is one of the admirable international Millennium Development Goals, championed by DFID.[2] The administrators were working to policies with a firm theoretical base, but the gulf between what is inevitably only a theoretical goal and the practical reality, which our patient displayed, can be very wide indeed.
The Almata Declaration of Health for All by the Year 2000 was heralded with acclaim in 1977. It promoted rural primary health care in poor countries but it became an empty slogan when the hope that it embodied was dashed, its goal hopelessly missed. Will the millennial goals fare any better? Is there the international will to make a real difference? We need a robust theology of the poor to grapple with global poverty, insists Eldryd Par In Africa, progress towards the goals is lagging behind what is needed: if they are to be met, much more will have to be done. The village in the dry season is a vignette of a desperate problem, scarcely surprising when there is less than $10 per capita for health in so many countries. While this example may seem extreme, it could be replicated, no doubt even more cogently, from poor countries all over the world. Nor is the problem only of remote rural people. The outcome of common diseases is unacceptably grim, even when good care is given in hospitals.
As I write this, The Lancet carries a commentary 'Rich nations, poor nations and bacterial meningitis'.[3] The commentary could have used the name of almost any disease. Most of us feel impotent as we consider the poor world, the stage on which the tale of two vehicles is played to increasing numbers year by year. We are often reminded that more than 1.2 billion people live in absolute poverty: they are the excluded from the great banquet of the industrialised world. Our government has pledged to increase the share of our gross national income that is to be used for international development, but rich governments remain parsimonious and protective, with honourable exceptions chiefly in northern Europe, and fall short of the minimum UN target.
It is abundantly evident that the poor in the poorest countries are excluded, but many who practise in the United Kingdom, including most of those who read Triple Helix, are only too aware of the relationship between domestic poverty and ill health among those who are excluded here.[4,5] The Black Report, the Acheson Report, and a flow of papers and of brave comments present inequality as unacceptable. The plight of the poor, euphemistically described and analytically graded as the socially deprived, is a standing rebuke to the consumer society, and their health is a challenge which is not getting any less.
Much is being done by various government initiatives, but this is only the tip of the iceberg. An issue of the British Medical Journal last year and its title, Health of the excluded,[6] was a needed reminder. The cover picture was a song without words - five children, on what appeared to be an estate, three without shoes and all without much of a chance.
Those who work for or among the excluded are the very stuff of motivation and inspiration for many. Who has not heard of Mother Theresa and the destitute of Calcutta? At which modern public figure's funeral, would a poor man say, as was said at the funeral of the seventh Earl of Shaftesbury, 'We shall never see his likes again: we loved him and he loved us'? When Dr Matthew Lukwiya died of Ebola fever in Gulu, Uganda, the BMJ leading article emphasised that he had chosen to work 'in the same isolated hospital for 15 years'. It also commented that, while some deprived areas in the United Kingdom face overwhelming difficulty in recruitment, the doctoring of deprived areas cannot rely on exceptional people.[7]
The poor, the deprived, the excluded, whether in the subsistence societies of the poorest countries or at the margins of our affluent consumer society, have needs which must not be submerged by a wave of international goals and resolutions or swept aside with a barrage of numbers and targets.
If we are to grapple with them and their demands on us, we need to have a theology of the poor. The thinking and biblical foundation of Ronald Sider's Rich Christians in an Age of Hunger [8] is an excellent place to start, together perhaps with a rereading of the book of Amos. At the beginning of his ministry, Christ announced that he had come to preach good news to the poor,[9] and at the end of his ministry he charged his disciples to go and make disciples of all nations.[10] In much of the twentieth century, the Christian medical response to the call of Christ was to go overseas, 'into all the world', and serve the poor, the stigmatised and the Kingdom. The new radicalism of the CMF might find expression, both in bringing the needs of the UK poor to its members and in championing work in deprived areas. It was often very hard for the early workers overseas: it is no less hard in any deprived society today.
