These thoughts express my own understanding based on a limited experience of working mainly in African countries since 1967 and for the Christian Medical Fellowship and MMA HealthServe from 1995 to 2001. These six years provided an opportunity to review the previous African experience that was mainly secular with its mistakes, prejudices and undeserved blessings. My comments are addressed primarily to those concerned with the provision of basic healthcare for the poorest people of the world.
Community healthcare mission can be based on a hospital or independent of a hospital and in a mission situation and is best seen as a part of community development. State provided community healthcare is often present at least in embryonic form and may be well developed in some countries. Mission professionals including doctors may also be providing community healthcare but it is to the Christian doctor (or other health professional) considering a hospital based mission call that these remarks are addressed.
This article makes no attempt to deal with the very real problem of how to work long term in a developing country situation and still maintain a foot in the door at home It merely tries to see ways in which a UK trained doctor might be of Christian service in the overseas situation. As regards issues such as re-accreditation even for the secular medic. the future of a career is to a large extent unknown. (see BMJ Oct12 2002 vol325:790 Your career:planning for the unexpected. See also Dr Andrew Fergusson, Dr Strengthsprove – or How I Learned to Stop Worrying and Love Revalidation HealthServe2002, 8:14-15., and the new edition of 'Short-Term Christian Medical Service Overseas' from CMF).
Spiritual Considerations
A Christian health professional might work in an academic, government or mission hospital. In all these situations it is vital that any attempt at Christian medical mission should be in keeping with Jesus declaration recorded in Luke 4:18-19 which in turn is a quotation from Isaiah 61:1-2. These aims must be distinguished from any man centred agenda. They must be party to the ultimate aims of the Kingdom of God. These are the glory and worship of God with justice and righteousness for all people and creatures. (For example, see Rev 5:10 and 6:9-11). For the Christian practitioner best practice can only be achieved with these aims. A Bible or other missionary training is not always essential, and might well be a hindrance in terms of loss of time, money and clinical experience. The essential means of grace include a prayerful, Bible reading lifestyle and membership of local sending and receiving churches. But the hard-pressed health professional in a culturally remote situation, whether national or expatriate, needs more opportunity for spiritual growth and support than is often available. The preaching and teaching available in the local church may be inadequate for his or her needs. The national church in a mission situation is meeting the needs of the local population in a situation deprived of resources and training. The national pastors and evangelists may themselves benefit from more teaching than would otherwise be available to them. The responsibility of the overseas mission organisation may be more to these workers than to the local population. The situation may be different in large urban situations where secular service and membership of a larger church may be the right way forward.
Work situations, including Christian mission, will never be ideal. But it is still important to choose the situation carefully and most importantly in the light of what one believes to be and accepts as the will of the Lord. Today the main secular humanist agenda toward the poor, into which Christian organizations may be drawn, is an economic one often based on a market mindset. This regards the poor in two categories. Perhaps one third can be delivered from poverty to the advantage of the global economy. The remainder are disregarded and from an economic point of view presumably it would be best if they ceased to exist. Rev 6 and especially verse 7 describes the processes by which this may happen. (For the wild beasts of the earth might be substituted unbridled business practices).
To my understanding, any business-based approach to medical mission is likely to fall into this health and wealth trap. By definition medical mission is taken to those who are unable to respond to a service offered on business lines. The service is offered on a sacrificial basis in terms of income and of career though not of professional fulfilment. Secular humanism and globalisation may add persecution to the deprivations of medical mission. They also give the Christians the opportunity to respond with Kingdom alternatives to neglect and oppression.
It may be helpful to distinguish the mission hospital from the church or other Christian hospital. As the local church develops and becomes able to take over the running of a mission hospital either as part of a denomination or as part of a non-denominational organisation, the aims of the hospital may be broadened to include the provision of a Christian service to a local community that is no longer trapped in poverty. At the same time it may lose its overseas support and the requirements for sustainability change. This article is about the mission hospital in a situation of gross poverty although the change to a locally sustainable one may be gradual. This traditional mission hospital is possibly still most often appropriate in sub-Saharan Africa than in many other parts of the world.
Professional Considerations
Local requirements to practice are likely to include registration with a national medical, nursing or other professional council (where these exist) and its own requirements for continuing professional education, and possibly for professional audit and revalidation. However the requirements for revalidation at home may well help in fulfilling local requirements. The danger is that they will make it difficult or professionally sacrificial to stay overseas though the longer the stay the greater the value to the local population. Healthcare aid agencies based in the UK may develop methods of validating those who work in developing country situations.
However these are likely to be related more to short-term disaster situations than the ongoing work of a district hospital and community development. In large cities there may be opportunities to serve in academic institutions. The main value of such work is in the teaching. The clinical work may be limited by problems of resources, administration and competition or lack of support from national colleagues with private practice interests. Working in private clinic situations may provide opportunities to serve the poorest though when referral to a larger institution is required the outcome may be disappointing. Encouraging students to consider working in deprived parts of the country in secular or church hospitals and participating in visits to these places can contribute to medical mission.
In rural areas the regional hospital providing tertiary level care may also see a rather selected group of patients. However it is likely to be the best situation for a doctor with specialist training and experience to work. Such hospitals have an important role in both service provision and teaching and also as a backup when the district type hospital finds itself without a key person or facility or doctor. Visits to district hospitals in the region, whether church or government run, need to be given priority and may result in a reduction of workload by reducing patients referred to the tertiary level of care hospital. In mission situations doctors planning to work in district type hospitals should be adequately prepared by first working with specialists in a referral hospital.
The mission and the government district hospital providing secondary level care often lacks experienced doctors if it has any at all. An alternative to doctors is being developed in those called Assistant Medical Officers (AMO) who may have been given the opportunity to upgrade from being a clinical or medical assistant. Both junior doctors and AMO's value the partnership of more experienced clinicians. AMO's have achieved excellent outcomes from certain operations such as Caesarean section but will not be so experienced in deciding when surgery is indicated and which operation would be most appropriate.
The district hospital is the closest one to the community at which the clinical knowledge, experience and skills of a doctor are needed. If a section of the population is being neglected by design or default this is where it will be found. I don't think the hospital surgeon or obstetrician would be spending his time well to make routine visits to many clinics in a rural area which involve long and difficult journeys but occasional visits will help him to keep hospital management decisions in perspective. He can at the same time see how well those who do make routine visits are coping in supervisory and teaching roles and may be pleasantly encouraged. Together they can discuss issues and may identify sections of the population such as schools that are being neglected in health education such as for AIDS prevention.
In whatever situation one works the care needs to be appropriate in terms of medical needs, resources and culture. There are endless opportunities to audit the work and try to rationalise how you work with a national health budget that may be a dollar or two per person per year, most of that being consumed centrally. In practice you look at the length of the queue and the clock, thinking of your colleagues' needs and adjust the time spent per patient accordingly. This is not so much rationing resources as sharing them. It may be harmful to run a booking system for clinics or theatre when a patient may have saved up for months to come today and if sent away is unlikely ever to return. Priorities may not always be best determined by statistics. For example WHO figures for the global burden of disease, leading causes of death and disability indicate a set of priorities for preventive and curative health services (BMJ Oct 26 2002 Vol 325 under Fillers). This might for example indicate a relatively low priority for the provision of operative deliveries. But one such successful delivery has a big impact on the local community and opens the way to discuss issues that have so far been suppressed or ignored. Such issues include the prevention of the spread of HIV in schools or the use of bed nets to prevent malaria.
Medical mission priorities raise another issue. The church is not there to provide nationwide health services, however poor the alternative services might be. Its call to heal is primarily to those who have been neglected by the local or the global community. They will often need hospital care and will help identify the needs of the most neglected communities for first level curative, preventive, and palliative care. In doing this it may reach individuals with the good news of peace with God through sins forgiven. But its first function is to honour its Lord and verify the integrity of the good news it brings free of any man made agenda.
Relationships are essential to management especially in healthcare and in mission. Clinicians must relate to non-clinical managers but equally non-clinical managers must be welcome in clinical situations such as ward rounds and must see and feel what is happening. Ideally both would share in a common training before specialising. In some areas of practice there are ethical disagreements between professions, and these must be clearly identified and a modus operandi for working together agreed in advance.
Adjustment to Change
Changes in global and local health, culture, security and economics are very rapid, but the Christian will want to be found busy when the Master returns or calls him home. He should be ready to see new opportunities and let go of those no longer useful. Mission societies may have to retrench but may be able to second partners or associate with expatriate healthcare professionals and provide pastoral care for them on the field. Job descriptions may need to be changed and to recognise that experienced nurses or paramedics are performing traditionally doctor's roles. Working in developing country situations and being Christian should make one better able to see the need to change and to act on it. With no hidden agenda and no vested interests other than kingdom ones and a security based on the sovereignty of God we should feel free to serve wherever led.
For information and guidelines for professionals working overseas visit the UK Department of Health
For further information and advice on short and long term mission opportunities contact the MMA HealthServe Office, or visit the vacancies section.
Community healthcare mission can be based on a hospital or independent of a hospital and in a mission situation and is best seen as a part of community development. State provided community healthcare is often present at least in embryonic form and may be well developed in some countries. Mission professionals including doctors may also be providing community healthcare but it is to the Christian doctor (or other health professional) considering a hospital based mission call that these remarks are addressed.
This article makes no attempt to deal with the very real problem of how to work long term in a developing country situation and still maintain a foot in the door at home It merely tries to see ways in which a UK trained doctor might be of Christian service in the overseas situation. As regards issues such as re-accreditation even for the secular medic. the future of a career is to a large extent unknown. (see BMJ Oct12 2002 vol325:790 Your career:planning for the unexpected. See also Dr Andrew Fergusson, Dr Strengthsprove – or How I Learned to Stop Worrying and Love Revalidation HealthServe2002, 8:14-15., and the new edition of 'Short-Term Christian Medical Service Overseas' from CMF).
Spiritual Considerations
A Christian health professional might work in an academic, government or mission hospital. In all these situations it is vital that any attempt at Christian medical mission should be in keeping with Jesus declaration recorded in Luke 4:18-19 which in turn is a quotation from Isaiah 61:1-2. These aims must be distinguished from any man centred agenda. They must be party to the ultimate aims of the Kingdom of God. These are the glory and worship of God with justice and righteousness for all people and creatures. (For example, see Rev 5:10 and 6:9-11). For the Christian practitioner best practice can only be achieved with these aims. A Bible or other missionary training is not always essential, and might well be a hindrance in terms of loss of time, money and clinical experience. The essential means of grace include a prayerful, Bible reading lifestyle and membership of local sending and receiving churches. But the hard-pressed health professional in a culturally remote situation, whether national or expatriate, needs more opportunity for spiritual growth and support than is often available. The preaching and teaching available in the local church may be inadequate for his or her needs. The national church in a mission situation is meeting the needs of the local population in a situation deprived of resources and training. The national pastors and evangelists may themselves benefit from more teaching than would otherwise be available to them. The responsibility of the overseas mission organisation may be more to these workers than to the local population. The situation may be different in large urban situations where secular service and membership of a larger church may be the right way forward.
Work situations, including Christian mission, will never be ideal. But it is still important to choose the situation carefully and most importantly in the light of what one believes to be and accepts as the will of the Lord. Today the main secular humanist agenda toward the poor, into which Christian organizations may be drawn, is an economic one often based on a market mindset. This regards the poor in two categories. Perhaps one third can be delivered from poverty to the advantage of the global economy. The remainder are disregarded and from an economic point of view presumably it would be best if they ceased to exist. Rev 6 and especially verse 7 describes the processes by which this may happen. (For the wild beasts of the earth might be substituted unbridled business practices).
To my understanding, any business-based approach to medical mission is likely to fall into this health and wealth trap. By definition medical mission is taken to those who are unable to respond to a service offered on business lines. The service is offered on a sacrificial basis in terms of income and of career though not of professional fulfilment. Secular humanism and globalisation may add persecution to the deprivations of medical mission. They also give the Christians the opportunity to respond with Kingdom alternatives to neglect and oppression.
It may be helpful to distinguish the mission hospital from the church or other Christian hospital. As the local church develops and becomes able to take over the running of a mission hospital either as part of a denomination or as part of a non-denominational organisation, the aims of the hospital may be broadened to include the provision of a Christian service to a local community that is no longer trapped in poverty. At the same time it may lose its overseas support and the requirements for sustainability change. This article is about the mission hospital in a situation of gross poverty although the change to a locally sustainable one may be gradual. This traditional mission hospital is possibly still most often appropriate in sub-Saharan Africa than in many other parts of the world.
Professional Considerations
Local requirements to practice are likely to include registration with a national medical, nursing or other professional council (where these exist) and its own requirements for continuing professional education, and possibly for professional audit and revalidation. However the requirements for revalidation at home may well help in fulfilling local requirements. The danger is that they will make it difficult or professionally sacrificial to stay overseas though the longer the stay the greater the value to the local population. Healthcare aid agencies based in the UK may develop methods of validating those who work in developing country situations.
However these are likely to be related more to short-term disaster situations than the ongoing work of a district hospital and community development. In large cities there may be opportunities to serve in academic institutions. The main value of such work is in the teaching. The clinical work may be limited by problems of resources, administration and competition or lack of support from national colleagues with private practice interests. Working in private clinic situations may provide opportunities to serve the poorest though when referral to a larger institution is required the outcome may be disappointing. Encouraging students to consider working in deprived parts of the country in secular or church hospitals and participating in visits to these places can contribute to medical mission.
In rural areas the regional hospital providing tertiary level care may also see a rather selected group of patients. However it is likely to be the best situation for a doctor with specialist training and experience to work. Such hospitals have an important role in both service provision and teaching and also as a backup when the district type hospital finds itself without a key person or facility or doctor. Visits to district hospitals in the region, whether church or government run, need to be given priority and may result in a reduction of workload by reducing patients referred to the tertiary level of care hospital. In mission situations doctors planning to work in district type hospitals should be adequately prepared by first working with specialists in a referral hospital.
The mission and the government district hospital providing secondary level care often lacks experienced doctors if it has any at all. An alternative to doctors is being developed in those called Assistant Medical Officers (AMO) who may have been given the opportunity to upgrade from being a clinical or medical assistant. Both junior doctors and AMO's value the partnership of more experienced clinicians. AMO's have achieved excellent outcomes from certain operations such as Caesarean section but will not be so experienced in deciding when surgery is indicated and which operation would be most appropriate.
The district hospital is the closest one to the community at which the clinical knowledge, experience and skills of a doctor are needed. If a section of the population is being neglected by design or default this is where it will be found. I don't think the hospital surgeon or obstetrician would be spending his time well to make routine visits to many clinics in a rural area which involve long and difficult journeys but occasional visits will help him to keep hospital management decisions in perspective. He can at the same time see how well those who do make routine visits are coping in supervisory and teaching roles and may be pleasantly encouraged. Together they can discuss issues and may identify sections of the population such as schools that are being neglected in health education such as for AIDS prevention.
In whatever situation one works the care needs to be appropriate in terms of medical needs, resources and culture. There are endless opportunities to audit the work and try to rationalise how you work with a national health budget that may be a dollar or two per person per year, most of that being consumed centrally. In practice you look at the length of the queue and the clock, thinking of your colleagues' needs and adjust the time spent per patient accordingly. This is not so much rationing resources as sharing them. It may be harmful to run a booking system for clinics or theatre when a patient may have saved up for months to come today and if sent away is unlikely ever to return. Priorities may not always be best determined by statistics. For example WHO figures for the global burden of disease, leading causes of death and disability indicate a set of priorities for preventive and curative health services (BMJ Oct 26 2002 Vol 325 under Fillers). This might for example indicate a relatively low priority for the provision of operative deliveries. But one such successful delivery has a big impact on the local community and opens the way to discuss issues that have so far been suppressed or ignored. Such issues include the prevention of the spread of HIV in schools or the use of bed nets to prevent malaria.
Medical mission priorities raise another issue. The church is not there to provide nationwide health services, however poor the alternative services might be. Its call to heal is primarily to those who have been neglected by the local or the global community. They will often need hospital care and will help identify the needs of the most neglected communities for first level curative, preventive, and palliative care. In doing this it may reach individuals with the good news of peace with God through sins forgiven. But its first function is to honour its Lord and verify the integrity of the good news it brings free of any man made agenda.
Relationships are essential to management especially in healthcare and in mission. Clinicians must relate to non-clinical managers but equally non-clinical managers must be welcome in clinical situations such as ward rounds and must see and feel what is happening. Ideally both would share in a common training before specialising. In some areas of practice there are ethical disagreements between professions, and these must be clearly identified and a modus operandi for working together agreed in advance.
Adjustment to Change
Changes in global and local health, culture, security and economics are very rapid, but the Christian will want to be found busy when the Master returns or calls him home. He should be ready to see new opportunities and let go of those no longer useful. Mission societies may have to retrench but may be able to second partners or associate with expatriate healthcare professionals and provide pastoral care for them on the field. Job descriptions may need to be changed and to recognise that experienced nurses or paramedics are performing traditionally doctor's roles. Working in developing country situations and being Christian should make one better able to see the need to change and to act on it. With no hidden agenda and no vested interests other than kingdom ones and a security based on the sovereignty of God we should feel free to serve wherever led.
For information and guidelines for professionals working overseas visit the UK Department of Health
For further information and advice on short and long term mission opportunities contact the MMA HealthServe Office, or visit the vacancies section.
