The moral and theological argument for a global perspective on healthcare

In recent years, global citizenship has become a popular way of framing the concept and the attitude that our world's people and systems are interdependent, and that we have a responsibility to cross-cultural competence and engagement in cross-community problems. The phrase has grown particularly popular within educational circles and its dimensions generally coalesce around the ideas of social responsibility, global competence and global civic engagement. (1) A useful description of a global citizen is 'someone who understands interconnectedness, respects and values diversity, has the ability to challenge injustice, and takes action in personally meaningful ways.' (2)

To what extent should Christians regard themselves as 'global citizens'? 'Our citizenship is in heaven,' the apostle Paul told the Philippian Christians in the first century AD. (3) For Christian believers, the foremost recipient of our loyalty is neither a nation state or humankind in general, but God himself.

However, far from disconnecting us from human problems, a Christian world view provides an objective rationale for compassionate engagement with the problems and concerns of local and global communities. Uniquely amongst God's creations, human beings were created with 'the image of God', (4) a designation of multi-layered meaning, but which indicates at least in part a responsibility to represent God's character and will, over all creatures and environments in this world.

Scripture teaches us that God is neither remote nor indifferent to pain and suffering, being described by the psalmist David as 'a compassionate and gracious God, slow to anger, abounding in love and faithfulness'. (5) The incarnation itself serves as a demonstration par excellence of God's intimate, personal approach with the problems of a fallen world. When Jesus was on this earth, his priority was to preach and demonstrate the good news of the kingdom of God (6) - good news for broken souls, but also good news for broken bodies and relationships. Jesus's compassion was not limited to those who loved him or obeyed him, but was administered to all those in society, believers or not who sought his help. Jesus's parable of the faithful outsider (the good Samaritan) taught that the Scripture's admonition to 'love your neighbour' was a demanding instruction to meet human needs wherever we find them. (7) Jesus also taught that the response we make to physical and relational needs was a direct indicator of our salvation status; '"whatever you did for one of the least of these brothers and sisters of mine, you did for me."' (8) The key ideas of global citizenship thus find a robust theological underpinning in the Christian faith. Christians can be enthusiastic advocates for an outlook that understands our responsibilities are not simply to family, friends and local communities, but to all people.

The idea of global citizenship should have strong resonance and significance for Christian healthcare professionals. Healthcare provision should be conceived of as a globally connected effort towards the reduction or alleviation of human suffering. The inequity in healthcare provision between high-income countries (HICs) and low/middle-income countries (LMICs) is well known. (9) This injustice should rankle with Christians. In response to the empty religiosity of Israel, God spoke through the prophet Isaiah: '"Is not this the kind of fasting I have chosen: to loose the chains of injustice and untie the cords of the yoke, to set the oppressed free and break every yoke?"' (10)

The mutuality of healthcare problems

The argument for a global perspective in healthcare is not just a moral or a theological one but is one of practical reality. Although the resources available for meeting health challenges varies greatly around the world, many healthcare challenges are inter-connected and share very similar characteristics. The Royal College of Physicians and Surgeons of Glasgow published a policy report in 2017 which evaluated the importance of global experience and perspective in the Scottish NHS. (11) Amongst this report's key findings were the following:

There is much commonality in the healthcare challenges faced by high-income countries (HICs) and low or middle-income countries (LMICs), such as in:

• Infectious diseases: disease epidemics and drug-resistant infections do not respect international boundaries and solutions require transnational ideas and cooperation.
• Non-communicable diseases: both HICs and LMICs face an increasing burden of cardiovascular and respiratory disease, cancer, diabetes and mental illness, and have similar challenges in prevention and chronic disease management.
• Rising costs of care provision and competition for skilled care workers: in many countries, populations are aging, use of technology is increasing and there is competition for skilled health service workers, making achievement of equitable, affordable care difficult.
• Providing equitable services to remote and rural communities: there are worldwide difficulties in recruiting and retaining staff for rural areas and providing health equity to these populations.

The mutuality of benefit from healthcare cooperation

Since many healthcare problems are inter-connected, so are the solutions. Cooperation between health systems takes many different forms, via international organisations such as the World Health Organization, through intergovernmental agreements, to institutional partnerships and often individual commitments.

It has been increasingly recognised that cooperation between personnel in HICs and LMICs can bring mutual benefits to both systems. It is essential that such cooperation occurs thoughtfully and ethically. (12)

From the LMIC perspective, there is limited empirical data as to the benefits they obtain from HIC healthcare worker involvement, but the available evidence does point to the following encouraging outputs: (11)

• reduced morbidity and mortality
• improved knowledge, skills and confidence of health workers
• improved quality of care and new services
• enhanced training and education capacity
• improved institutional governance, policy development and system change

There is also clear academic evidence that individuals and systems in HIC settings can derive a wide variety of benefits when HIC personnel undertake training, service delivery or development in a LMIC setting. (13),(14) These individual benefits come in the form of both technical and non-technical skills development, and often include a sense of personal renewal and enhanced job satisfaction. Benefits for HIC healthcare systems can include enhancement of recruitment and retention, system learning and capacity building, professional development of the workforce, improved patient experience and reputational development. (15),(16)

What now?

Christian healthcare professionals have opportunities to express their faith through action in different spheres:

• service provision in LMICs - short and long-term.
• teaching, training and personal development.
• campaigning and lobbying home governments, professional associations, and international organisations on issues that would improve equity of access and quality for neglected patients around the world.

Christians have a responsibility towards human needs in communities both local and global. Inequalities in the experience of health and healthcare around the world should provoke Christians to action.

We can be confident that engagement in the health problems of the developing world is not only a moral choice, but one that often provides a mutuality of benefit to both the high and low-income settings that they connect.

Stuart Fergusson is a surgical trainee in Scotland. He was recently the co-author of a major policy report from the Royal College of Physicians and Surgeons of Glasgow on the value of international volunteering.