Jonathan Fletcher explores inner-city mission overseas.

Oorn* was six years old when he fell a foot or so from some monkey bars and broke his femur. His 13-year-old cousin carried him out through the winding lanes of the slum to the main road by the port where she flagged down a motorcycle taxi. Bangkok is not short of hospitals and Oorn was taken to our local. It is not a bad hospital, if you can pay. But it also takes part in the Thai government's 30 Baht card scheme whereby low income families can qualify to be seen by a doctor for the equivalent of 60 pence. Oorn's card is registered there. On arrival he waited in the emergency department for a couple of hours without any analgesia. When he arrived on the ward his leg was put in traction without any analgesia, and he was slapped by the nurses for crying too loudly. Then western money stepped in and his experience was transformed.

Oorn was transferred to a different hospital and given suitable analgesia. He could then talk and tell the story of his accident. He was investigated appropriately and his low-trauma femoral fracture managed with surgery and a hip spica cast. Being a child from the slum affected not only Oorn's risk of adverse health (his malnutrition contributed to his injury), but also his treatment when he needed it. The hospital would not pay for medicines or investigations for a child on the 30 Baht scheme - it would cost them too much. But this unequal treatment costs Oorn and thousands like him much more.

Pi Nat is a friend who told me the story of giving birth to her child at the local government hospital on the 30 Baht scheme. She thoroughly intended to breastfeed her child. Standard procedure at this hospital is for the child to be removed from the mother at birth and kept separate from the mother for six to eight hours. Something about 'getting used to the air'. Despite all of her requests the staff would not give Pi Nat her new baby to feed. All the babies are bottle-fed before the mother can even see them. Mothers who have the money to access better hospitals perhaps have more likelihood of being heard.

Pi Pon drinks too much alcohol, as does his wife. In one drunken fight she managed to land a pair of pliers squarely on his head. On arrival at our local hospital the staff chose to completely ignore Pi Pon's 30 Baht card and quoted him 4000 Baht to suture his laceration closed. Pi Pon declined to pay and returned home where his wound was closed by his drunk friend on the street.

Ong was about 18 months old when he had his second febrile convulsion, but this time the fitting wouldn't stop. His mum took him to our local hospital who admitted him but made no attempt to stop the seizures or reduce the temperature. Ong suffered brain damage and now lives with severe epilepsy.

These stories offer a glimpse of the health costs of being labelled a slum resident, a picture of how the urban poor find themselves marginalised and disadvantaged, just by being poor.

A harsh reality

From these stories it might sound like the 30 Baht scheme is terrible, but at least it is a step towards some of my neighbours getting seen by a doctor. Urban poverty is harsh and illness reveals some of its darkest facets. The system seems set up to discourage the poorest members of society from accessing it fully.

A visit to hospital will likely involve missing work to spend an average of four to six hours queuing to see a doctor. It may well involve missing a second day to go for a test, then a third day to get a diagnosis, then having to pay over-the-counter prices for any medicines. For some of the poorest, losing just a day's wage may mean not eating the next day, losing two or three day's wages may mean not paying the rent that month, and the informal economy of the slum is often enforced with violence or eviction. Some people borrow money, but not from any reliable bank. Consequently lots of people self-diagnose, self-treat, leave things alone and worry, present too late or stop caring about their health altogether without the hope that they could make any difference.

Inspired and humbled

Ten months ago, I moved with my family into Bangkok's biggest and oldest slum, Klong Toey. It is really a conglomeration of 23 smaller slum communities huddled together in about two square kilometres of Port Authority land with an estimated 100,000 residents. The figures show that some residents are doing well for themselves here but others struggle to make ends meet each day. Material poverty is very visible here and is accentuated by its location alongside the world of high-rises, the flourishing business and commercial districts of modern Bangkok.

My wife Elise and I, along with our two boys, Elliot and Sam, have joined a small Missional Order called Urban Neighbours of Hope. (2)

As Urban Neighbours of Hope, we 'immerse ourselves in the life of neighbourhoods facing urban poverty, joining the risen Jesus to seek transformation from the bottom up'. This mission statement both inspires and humbles us. Elise and I are currently putting most of our time into language learning and studying the culture. We want to use this time with our eyes and ears open to see what life is really like for our neighbours, even though there is little we can do to help. I strongly feel the frustration of not yet being able to use my communication skills or formal medical knowledge but we intend to be here for the long term and maybe the current powerlessness is helping me to better identify with my neighbours.

So why move to a slum? Well, the world is changing. In 2009 the world's population became majority urban, (3) meaning that more than half of the people on this planet now live in cities. In 1800, only 3% of humankind lived in cities. It is estimated that by 2100 the figure will be nearly 90%. (4) In 2007, the urban slum population hit one billion, (5) and has continued to rise since then. It is estimated that right now more than one in six people in the world live in an urban slum. (6) Population growth and massive urbanisation doesn't seem to be slowing down. Some predictions put proportions of people living in urban slums as high as half of the world's population by 2050. (7)

Rethinking medical mission

UN-Habitat identifies slums using five characteristics:
1. Inadequate access to safe water
2. Inadequate access to sanitation and infrastructure
3. Poor structural quality of housing
4. Overcrowding
5. Insecure residential status

These five characteristics make it easy to see how health might be affected by living in a slum. Looking around through my GP eyes it sometimes seems like just about anywhere else on earth. People drink too much alcohol, smoke too many cigarettes, eat too much sugar and get all sorts of infectious diseases. We have a few characteristic twists like methamphetamine abuse, glue sniffing, gang violence and motorcycle trauma, but essentially there are the same problems that I became familiar with in general practice in the UK.

Here, access is the problem. Here a neighbour is denied care for being poor, for having been born in the wrong part of town. Meanwhile, the rich and super-rich access some of the best plastic surgery in the world in 'five star' private hospitals.

In urban populations, the problem of access to healthcare is more than just physical distance, and this is where I think medical mission comes in. Yes, it is a great witness to go out to the ends of the earth, to the remote locations and build mission hospitals for the poor who have no healthcare. But isn't it also great kingdom work to apply the gospel to the issues which disadvantage our poor neighbours who live 500 metres from a multi-million pound health facility. The gospel speaks into the treading down of the poor by the rich, the unjust systems which advantage the already-privileged few. The gospel holds out the hope of a new way, a kingdom way of living, where inequality is lessened and the hope of real change becomes possible, where a new community can be formed and real care can happen.

Jesus reminds us in the parable of the sheep and the goats that he will look on how we have responded to him in how we respond to 'the least of these my brothers' - the stranger, the naked, the sick, the prisoner. (8)

The world is changing, in fact the world has changed and the vast numbers of poor arriving in urban centres around the world need to both access good healthcare and hear the good news of the one who 'does not look at the things people look at. People look at the outward appearance, but the LORD looks at the heart'. (9) They need to meet him who 'a bruised reed he will not break, and a smouldering wick he will not snuff out. In faithfulness he will bring forth justice'. (10)

No easy answers

In terms of solutions - I have no easy answers. I'm not sure there are any. I know that presence with our neighbours is part of it, sharing place, walking alongside, cheering people on, knowing and being known. Perhaps training armies of community healthcare workers, or effecting change from within corrupt hospital systems, who knows? But treating our neighbours with dignity and offering the hope of a different future, a future made possible by the good news of the gospel, that is part of our work here in Klong Toey.

For me, God began by opening my eyes to the reality of poverty, both in the UK and worldwide. Before moving across the world I moved with my family across town onto the council estate where most of my patients lived. That was a wonderful year full of life and relationship and we wondered why it had taken us so long to give up our 'middle-class' lifestyle! God was calling us on to Klong Toey and that has meant, for the moment, laying down being able to practise as a doctor, laying down feeling useful, needed, powerful. Urban Neighbours of Hope does not have a particular medical focus to its work, but being here I am trying to see how God is planning to use all that he has prepared in me. This downward journey has truly been where I have found myself transformed by God, where discipleship is hard but real. Jesus reminds us 'Whoever wants to save their life will lose it, but whoever loses their life for me will save it'. (11)

A growing need

How can you respond? Move across town and share the place of the poor? Learn a language really well? Engage in medical politics to effect systems change? Apply for jobs in hospitals that serve slums in world cities? Move to join a group working in an urban slum? Pray and give to people or organisations working with the urban poor?

May we be part of a generation of Christian doctors who follow Jesus to these dark and forgotten margins and meet him there in serving the urban poor. It may be the case that some of us are preparing for medical mission - but are we preparing for a world that no longer exists? The rapid urbanisation of the world compels us to consider medical mission in urban slums. As medical students with your whole career ahead of you, the next 40–50 years may be critical in the shaping of our new urban world. The numbers and the needs of the urban poor will only increase.

Back to Oorn, today his leg has healed well and he is back to his mischievous self. It is hard to imagine him in severe pain. The outcome has been good for him but the means is not sustainable. Cases like his go past unnoticed each day. Whilst using outside resources to step in and make a difference for one child holds value, it also raises many questions. Living here, sometimes all we can do is take comfort in imagining a different way - what would God's kingdom look like in this place, in this situation? How can we help develop a caring community? How can we stand up for the marginalised and effect change in an unjust system? We long to see God's kingdom come for our neighbours in this urban village we now call home.

If you would like to find out more about urban mission contact the CMF International Department, or contact Urban Neighbours of Hope: www.unoh.org