Why are so many people excluded from healthcare?

Being poor and disadvantaged is generally recognised as being 'bad for your health.' (1) The WHO Global Health Observatory (2) website displays striking differences in healthcare coverage according to country, education and poverty. But there are many other important reasons for exclusion from healthcare.

Factors on the 'supply side' include a lack of skilled and equipped staff, despite increased numbers trained in recent years. There are changing global health challenges such as the 'Double Burden of Malnutrition'. Many millions of children are severely malnourished. Severe Acute Malnutrition now kills more children than malaria. Conversely, many millions of obese adults have diabetes, hypertension and vascular disease.

Protocols, skills and supplies are often inadequate. Many millions still live far from healthcare services. There are varying viewpoints and scriptural interpretations about when life starts - at fertilisation, at implantation, or even later. This affects the type of family planning technologies that staff will discuss or provide. Differing viewpoints also affect the provision of harm reduction methods for HIV prevention, including condoms and clean needles. (3)

Factors on the 'demand side' include the stigma that often excludes people with mental illness, HIV, leprosy, albinism, epilepsy, and stillbirth. These are often deemed to be 'caused by bad spirits' and considered as needing treatment by traditional healers rather than healthcare professionals. Disabled people face particular stigma and difficulty in accessing healthcare.

With regard to sexuality, LGBT persons are judged by many Christian leaders, preventing access to diagnosis, treatment and care. The Archbishop of Canterbury, Justin Welby, apologised strongly for this judgment, but it persists. Power relations are critical. Many girls have their genitals cut and have no say about when they should marry or have babies. Mothers are often denied permission to visit clinics or deliver in a health facility. Women subject to domestic abuse are often too frightened to attend clinics. Conflict creates refugees, internally displaced people, migrants and prisoners, many of whom often face major problems in accessing healthcare.

How do people feel when they are excluded?
The Bible uses the word 'forsaken' (literally - giving up something that is valued highly). David cried out, 'Why have you forsaken me?' (4) Jesus used these words on the cross. (5) All humans are made in God's own image and are deeply loved by him. (6) By excluding or forsaking other humans, we turn our back on part of God's creation.

Responding to inequity

The Bible portrays covenants that support an individual's rights and protects them: by God for Noah, (7) Abraham (8) and Moses. (9) God, through Isaiah, warns, 'Woe to those who deprive the poor of their rights and withhold justice from the oppressed' (10) and exhorts people to 'seek justice, encourage the oppressed, defend the cause of the orphan and plead the cause of the widow'. (11)

Should these biblical values be implemented by a few inspired individuals, or by laws which aim to protect individuals and communities who are 'excluded'? For centuries, remarkable Christian healthcare professionals have provided outstanding care for the excluded. Christians are also exhorted to be 'salt and light', inferring the need to promote rights-based improved healthcare for the excluded.

During the Second World War millions of people were exterminated because of race and disability. Afterwards there was a desperate desire to create a culture of 'never again', enforced by law. The UN Universal Declaration of Human Rights (1948) was drafted and accepted by nearly every country. The statement by Hernán Santa Cruz, a senior Chilean politician involved in the drafting, is profound.
'I perceived clearly that I was participating in a truly significant historic event in which a consensus had been reached as to the supreme value of the human person, a value that did not originate in the decision of a worldly power, but rather in the fact of existing - which gave rise to the inalienable right to live free from want and oppression and to fully develop one's personality'. The 'supreme value of the human person' is strongly supported by scripture.

A decade later (1959) the Declaration of the Rights of the Child was widely adopted. Principle two stated that 'The child shall enjoy special protection ... by law and by other means, to enable him to develop physically, mentally, morally, spiritually and socially in a healthy and normal manner'. Interestingly, 'spirituality' was dropped by the WHO in its definition of health but has been reintroduced recently in WHO policies on palliative care. Such decisions have been influenced by articulate and powerful, often secular, lobby groups who seek to promote their viewpoints within law.

CMF supports 'a rights-based approach to life', building on biblical principles and being supported by the UN Declaration of Human Rights. At present, the legal basis for providing healthcare for the excluded is less strongly championed. There is important work to do on rights-based support for 'healthcare for the excluded', but is that all?

Compassion is crucial. It is a key attribute of God and believers are encouraged to be compassionate. In practice some healthcare professionals are deeply compassionate while others are not. Why? Strong influences from family and community members are important, but the Bible also emphasises more than 'trying to be compassionate'. It describes how believers are 'anointed with the Holy Spirit' and describes the 'fruit of the Spirit' as vital in building compassion - 'kindness, goodness, faithfulness, gentleness and self-control'. (12) Perhaps a key question that Christian healthcare professionals need to ask is 'How compassionate am I towards the excluded?' and 'How might God nurture compassion for the excluded within me?' We spend a lot of time on career planning, training and appraisals but how often do we, possibly with a trusted friend, review how we are progressing in our 'compassion score'? Words of Dietrich Bonhoeffer - written before his execution by the Nazis - are deeply challenging. 'God chooses people as his instruments and performs his wonders where one would least expect them. God is near to lowliness; he loves the lost, the neglected, the unseemly, the excluded, the weak and the broken.' (13)

How can healthcare professionals respond?

Becoming informed and being an advocate.
We can support organisations that campaign for the excluded such as Amnesty International, Tearfund, CAFOD, and World Vision. The Joint Learning Initiative on Faith and Local Communities is increasingly influential at the policy level. (14) In 2015, they organised the launch of the Lancet series on Faith and Healthcare at the World Bank. It documented the high coverage rates by faith-based healthcare groups for the poorest in Africa and the impact of some faith leaders who challenge prejudice, health-damaging behaviour and exclusion. (15) The International Development Departments of the UK, Germany and the USA also acknowledge the effectiveness of faith-based healthcare organisations in reaching the excluded. Several UN agencies, including UNAIDS and UNFPA, now have policy units focusing on faith based healthcare. There are full-time career and short-term contracts for healthcare professionals within such organisations. National faith-based healthcare organisations are also now more effective in their advocacy; provision of healthcare for slum dwellers in India for years has enabled ASHA to campaign effectively for improved social services, including healthcare, from national government. (16)

Working overseas as a healthcare professional.
There are inspirational accounts of Christian healthcare professionals who have worked in church-based healthcare programmes - 'medical missionaries'. Reviews by Schram (17) of those in Africa and Philip (18) of those in Asia make challenging reading. There are increasing opportunities for clinical and public health work, working alongside national colleagues - either short-term or long-term as reviewed in iSERVe (Global Connections) and through CMF. (19) The Royal College of Paediatrics and Child Health (RCPCH) organises mentored training programmes in developing countries. (20) There are many unfilled jobs in international NGOs working in acute humanitarian relief. Local community groups, including many Christian communities, are mentored by UK trained healthcare professionals as they identify some of the root causes of health problems and do something about it themselves. (21)

The term 'tropical medicine' describes clinical and public health programmes for malaria, HIV, TB, leprosy, helminthiasis, filariasis, schistosomiasis, malnutrition and appropriate technologies for surgery, obstetrics and ophthalmology - 'in the tropics'. With fast-developing antimicrobial drug resistance and outbreaks of unexpected infections such as the Ebola and Zika viruses, research is critical and international journals are now filled with research papers on 'tropical medicine'. Short and long-term research contracts are available for those with aptitude.

Insights from sociology, health economics and behavioural science are also crucial if adequate healthcare is to be accessed by the 'excluded'. The term 'global health' is now used to describe multidisciplinary ways of tackling disease and disability, especially among vulnerable people. There are strong research programmes and fellowships, especially for those prepared to maintain their core clinical discipline but work with others. (22)

'Implementation research' is increasingly recognised as being crucial, requiring rigorous methodology and the development of novel approaches.

Providing training

Many UK healthcare professionals now provide training through link programmes between NHS trusts and healthcare programmes overseas. The best provide a long-term link, making repeated short-term visits over a number of years. Tropical Health Education Trust (THET) (23) and Prime run excellent programmes; there are many others. CMF publications give invaluable guidance on these opportunities. (24) Internet and mobile phone-based support for healthcare such as HIFA2015 and CHILD 2015 and modern communications technology in radiology, histology and case conferences are increasingly used.

There are many jobs with Christian, multi-faith or secular organisations overseas. It is nearly always possible to join and contribute to a local Christian fellowship wherever you work. The term 'Christians in global health' best describes the remarkable range of ways in which Christian healthcare professionals can make a difference.

How to prepare

As with any decision in life, Christians are encouraged to be informed, examine scripture, pray and obtain wise, experienced advice. There are some general principles:

• Develop a professional, vocational career but be prepared to work outside that area - a UK trained clinical paediatrician might work overseas and treat severely malnourished children using home-based regimes.
• Develop relationships that last; keep communications going once you return to the UK. Work with some good mentors and meet people who are making a difference.
• Build capacity in your overseas colleagues. Much professional building in the UK is about 'self', whereas in global health it is about 'others'.
• Put more emphasis on planning for logistics, communications and sustainability than you do in the UK - become more socially and politically aware.
• Network as much as you can. Look at websites which are not of direct interest to your professional career. Read the Lancet and BMJ, both have global health editions.
• Understand your leadership and communication style and how that might need to change to optimally support overseas colleagues.
• Link with an active, multidisciplinary research and teaching department of global health in the UK.
• Review job lists - CMF, iSERVE, SCF, Medair.
• Be prepared to take some risks - to your career and your pride. Negotiate hard with your career development supervisors and trusts. They may need convincing of the benefits to you of working overseas. There are many positive examples you can quote.
• Marry the right partner. If you have children do not be too protective. Recognise that they may benefit enormously by living and learning overseas.
• Make a personal GHAP (Global Healthcare Action Plan) - discuss it with colleagues, your family and church as you plan it, put it into practice and nurture it.

In times past, work by Christian healthcare professionals in poor countries was for the 'chosen few'. Most remained in the UK, publicising, praying and supporting this outstanding work 'by those overseas' in many ways. However, the world has changed. Communications, careers, regulatory bodies, travel and technology are all different now. Developing a personal GHAP is no longer 'an option for some'. It is an 'opportunity for all'. Putting a personal GHAP into action will stretch you and your family more than you might imagine, but it will also stretch and grow your faith and professional life in ways that you might never envisage. At the very least, it can be a way of following the example of Jesus who came 'to proclaim good news to the poor...to proclaim freedom for the prisoners and recovery of sight for the blind, to set the oppressed free, to proclaim the year of the Lord's favour. (25)

Andrew Tomkins, is Emeritus Professor of International Child Health, Institute for Global Health, UCL.