How we keep up with the world is challenging. The February 21, 2011, Time magazine cover featured "2045 The Year Man Becomes Immortal" with an asterisk saying, "If you believe humans and machines will become one. Welcome to the Singularity movement." The article presented the advances in computer technology and artificial intelligence (Grossman, 2011). The rapidity of change has led The North American Missions Leaders Conference to plan a conference entitled, "Reset: Missions in a Context of Deep Change." The case statement for this conference refers to a definition of "deep change" from The Power of Pull (Hagel, Brown, & Davison, 2010), stating, "In the turbulent season of January 1964, poet philosopher Bob Dylan released his now classic song, 'The Times They are A-Changin.' Of course that is true of every generation, every moment in history. Time never stands still; change is constant. But not all change is created equal. The nature, scope, and pace of change in today's digital world is unprecedented. This is a different era, one where edges emerge and reshape the world with astonishing speed" (Moore, 2011, p. 1).
Of course none of this is taking God by surprise or is outside of his control (Isaiah 14:24). Christians need to keep abreast of God at work around the globe and be willing to change, modify, and reinvent how we go about bringing the message of Jesus to those who have not heard or believed.
Historically, early medical missionaries were sent to care for their fellow missionaries who were dying from tropical diseases (Van Reken, 1990). Healthcare personnel set up hospitals and clinics to meet overwhelming need. Modern medicine held great power for healing and helped the church gain credibility among nationals. But increasingly hospitals and clinics are expensive organizations to keep running. Mission organizations largely consist of theologians, missiologists, and pastors. Their goals relate to presenting the Gospel and planting churches. They have understood healthcare to be a valuable tool in bringing people to God, but now are evaluating whether or not scarce funding is best spent on healthcare missions. To many in the missions arena, healthcare is under the purview of healthcare professionals and not part of the mission mandate of the church. Although mission leaders may acknowledge that Jesus healed the sick as well as addressed spiritual needs, they do not always see that the gospel message and health are intrinsically related.
It is in this milieu that healthcare missions is being challenged. New trends are emerging or being redefined. Missionary nursing is moving away from clinical practice in hospitals and clinics where nurses worked long hours caring for the sick, dispensing medications, dressing wounds, delivering babies, and doing the administration work necessary to keep the institution running. This type of nursing is still practiced and will continue to be, but the "The Times They are A-Changin."
HEALTHCARE MISSION TRENDS
Trend 1: Moving away from curative medicine to community health development. The celebrated Alma Ata Declaration of 1978, with input from the Christian Medical Commission of the World Council of Churches, issued a battle cry of "Health for all by 2000." Community health development, with a focus on preventing diseases rather than treating them, was touted as the way to achieve health (Alma Ata, 1978). The late Dr. Carl Taylor who taught public health at John's Hopkins was a leader in this movement. Just prior to his death he spoke at the Global Health Missions Conference, recalling that the Church had practiced and advocated for an integrated wholistic approach for centuries (Taylor, Perry, & Smith, 2008).
Mission organizations involved in community development advanced the education sector by setting up schools, the spiritual sector by planting churches, the health sector by building hospitals and clinics; and the economic sector through agricultural development and later through microenterprise and business development. However, the professional public health sector chose to focus on vertical programming, focusing on one issue such as growth monitoring, oral rehydration and control of diarrheal diseases, breast-feeding, and immunizations—things that could be readily measured and managed. This differs from approaching health promotion from a wholistic, grassroots, community development perspective that is directed by community members and where multiple issues are addressed.
Healthcare needs to be provided on a continuum. Western dichotomist thinking can limit our approach to problems as "either/or" when we should be thinking "both/and." The dichotomy is not preventive versus curative healthcare; rather it should be prevention of disease as well as treatment. Curative healthcare is important: if I have appendicitis I want a surgeon who can remove my appendix, and antibiotics to treat the infection. Preventing diseases also is important yet only a small portion of healthcare dollars are allocated to promoting health and preventing disease compared to highly technical, and expensive, curative care.
What is community health development? I was involved in developing programs in Uganda using the community health development approach. Once, as our program was being evaluated by my director, we visited a home where the lay community health worker (CHW) had been visiting. My director asked the male head of the household what he had been taught by his CHW. The man answered, "She told us we needed to have a latrine, so I built a latrine." We inspected the latrine.
"What else did the health worker tell you?" my director asked.
"She said we should not dry our dishes on the ground, so I built a dish rack." We inspected the dish rack. On and on it went recalling teaching about immunizations, monitoring the children's growth and weight, houses for animals, and clean drinking water.
"So, you've done a lot of work here," said my director. "What difference has it made?"
The man thought for a minute and said, "We used to go to the clinic at least once a month, sometimes more often, for treatment. We haven't been to the clinic for six months. That has saved us a lot of money we can use to send the children to school."
Generally, it has been difficult to measure the development work done by Christian mission organizations. Many have not collected baseline data or invested in evaluation of outcomes or indicators, or data reported are questionable. We may see temporary improvements in "vertical programs" that are sustained as long as funding continues, but often the health issue reemerges when funding is diverted to newer programming or when other more urgent health issues take precedence. When HIV/AIDS emerged as a pandemic in Africa, efforts in controlling malaria and diarrheal diseases were given lower priority in order to address the emerging problem of HIV/AIDS even though many more were dying from malaria.
There are challenges associated with focusing on prevention. Financially, there are costs associated with training lay health workers and village health committees who teach prevention. Programs can be difficult to sustain as funding is often short term and requires results that take communities longer to achieve than funding provides. Keeping people healthy is difficult to measure and justify to funders. Curative care is tangible, but to say people are not getting sick isn't as measureable or exciting. Finally, if the program is successful, the credit goes to the hardworking community, not to the people who brought the program to the community. If a mission organization or a development agency is trying to raise funds for this work, they are often hard pressed to demonstrate what it is they are accomplishing.
Although the challenges seem daunting, the opportunities are great. Community health development follows a biblical model. Jesus went to villages teaching and healing. Health is brought to people's homes. Relationships between health workers and the people establish trust and are at the heart of sharing the gospel message. Community Health Evangelism (CHE) is an approach to community development that is being implemented worldwide through organizations such as LifeWind International and Global CHE Network (see Web Resources).
Trend 2: Moving away from practicing to teaching. As healthcare missions established curative centers, hospitals, health centers, and clinics, they needed personnel. In response, they began schools of nursing and educational programs for healthcare personnel. Over time, these educational institutions and mission healthcare centers became the backbone of healthcare and healthcare education in countries where western healthcare systems had not been present. When countries became independent from former colonial rulers, the newly formed governments became involved in regulating healthcare and healthcare education. Although some mission hospitals still train local personnel to carry out necessary healthcare functions within their institutions, increasingly nursing education is becoming formalized and standardized by government regulatory agencies. Nursing education is moving from hospitals to universities, just as it did in the United States. Currently, the International Council of Nurses (ICN) is looking at what constitutes basic nursing practice and education around the world (ICN, 2010).
As modern technology and improved curative medicine reaches developing countries, nurses need to have critical thinking skills to provide quality professional care. Nursing education in these countries needs updated curricula and teaching methodologies that will equip nurses with the knowledge and skills needed to provide care to their populations. Although some nursing knowledge and skills are universal and can be applied in any healthcare setting, designing a curriculum requires careful planning. The nursing curriculum that was in place in Uganda when I arrived in 1985 had been brought from England in 1972. The curriculum included content on ileal conduits (urostomy), while teaching nothing about measles until an advanced post graduate course in pediatrics. Rarely did Ugandans have an ileal conduit, yet half of the population was under 15 and children often died of measles. The Ministry of Health was given funding to revise this curriculum, to make it "comprehensive" to prepare a generalist as opposed to the enrolled/registered nurse or enrolled/registered midwife that was the basis of nursing at that time. Prior to going to Uganda, I had been involved in nursing education and curriculum development. There, we looked at the U.S. demographics and determined that the baby boomers were aging and the need for nursing in the future would include a large geriatric population. Although Uganda had elderly, a focus on pediatrics was a higher priority. Taking a curriculum from a developed country such as the United States would not educate Ugandan nurses to care for the people of Uganda.
The current need in missions is for nurse educators who are proficient teachers, can teach critical thinking skills, who appreciate the underlying cultural beliefs and practices of host countries, and can educate healthcare professionals to address the health-related issues affecting the society in which they practice. Missionary nurse educators need to be well-prepared professionally as they educate the nursing leaders of their host countries but also willing to set aside some technical knowledge and skills to adapt to the limitations of an emerging healthcare system. They may need additional education in conditions such as tropical diseases that do not commonly occur in northern latitudes.
Trend 3: Moving away from leading to following. Pioneering missionary nurses and physicians were people with many talents. Often, in addition to performing surgery, holding clinics, delivering babies, suturing wounds, and setting broken bones, they built buildings, repaired vehicles, secured funding, and preached the gospel. Their stories motivated many to follow in their footsteps. They are heroic people who sacrificed to bring health and the gospel to remote places.
Early missionaries were successful in raising up indigenous healthcare professionals, some of whom are successfully carrying on the work. However, these professionals face many challenges. They may lack access to the funding sources missionaries had or have cultural obligations not imposed on the missionaries. As people newer to faith, they may have questions about faith and health. For example, a Kenyan nursing student studying in Michigan asked me if I thought God was punishing Kenya with the HIV/AIDS epidemic for its past sins. Understanding in her traditional worldview that disease was thought to result from a curse by an ancestor led me to a discussion of a Christian worldview of suffering.
The changing role for missionaries isn't so much going and doing for people as it is coming alongside indigenous healthcare professionals to encourage, mentor, and nurture them as leaders. In places where the church is well established, missionaries must submit to the indigenous church leaders. This is often difficult for driven, well-educated missionaries who have been prepared as leaders whose models have been missionary heroes.
For over 20 years the model of partnership ministry teams (PMT) used by the Luke Society (2011), an organization I worked with in the United States, has been an effective means of establishing indigenous healthcare leadership. A North American ministry team, usually consisting of a healthcare professional and a person from the business community, travels annually to meet with the indigenous healthcare professional who feels called to bring health and the gospel to his or her people. Together they set goals and budgets for a healthcare program. The North American team helps raise the budget and prayer support for the project. The indigenous healthcare professional is responsible for leading and managing the project. The Luke Society regional coordinators in Africa and Latin America are now internationally recognized healthcare professionals taking on the responsibility of finding and mentoring others in developing countries.
The 2010 Nurses Christian Fellowship USA Global Project to Uganda for nursing students visited the Luke Society project in Kampala headed by Rebecca Wasswa, a "health visitor," the term for public health nurse in Uganda. Rebecca and her staff begin their days with devotions; their vibrant faith in God was evident in every aspect of their care for the community. One of the students observed that the way Rebecca knew each patient demonstrated how she took time to build relationships, seeing HIV+ patients as beautiful people needing care and support from their community. Rebecca is not just impacting nursing in Uganda, she has impacted the lives of students from the United States.
Trend 4: Moving from long-term to short-term missions. Before air travel and the Internet, missionaries sailed on ships to spend 7 years or more in distant lands, often leaving families and loved ones behind. Today, we fly around the world, crossing time zones with ease. Arranging for global trips is made relatively easy by the Internet where we book flights and pay with credit cards, then tell people of our plans and communicate while away via e-mail, cell phone, or Skype.
In 2007, 1.6 million Americans were sent by over 40,000 sending entities on short-term missions at an estimated cost of 3 billion dollars (Collins, 2007). The ease of communication and transportation has enabled Americans to experience missions first hand. Americans have been given great resources, made aware of the great need, and many sincerely desire to serve God by caring for the poor, widows, and orphans of the world (James 1:26–27). As caring professionals, nurses are naturally drawn to use their knowledge and skills in a missions context. Some have found a personal relationship with God by participating in short-term missions.
There are, however, challenges associated with short-term healthcare missions. Short-term projects often rely on local interpreters who may not understand medical terminology. Explaining a surgical procedure and obtaining an informed surgical consent can lead to misunderstandings. The importation and use of pharmaceuticals needs to follow World Health Organization (WHO) guidelines (1999). The packaging of prescriptions requires proper containers with clearly written labels. Instruction in how drugs are to be taken can be challenging in areas where illiteracy is prevalent. (See Seager, Seager, & Tazelaar, 2010 for a discussion of these issues).
Cultures with worldviews that attribute disease and suffering to causes other than those held by scientifically based healthcare professionals may result in misinterpretation of who is doing the healing. A nurse from the United States may be put into the same category as a witch doctor or shaman; the rituals of health assessment (blood pressures, stethoscopes, percussion) can be viewed as similar to tossing bones or other incantations done by shamans, the medicine dispensed as no different than potions used to ward off curses. Our desire is that God would use us to bring his healing to their lives, but is this how our care is understood?
Because Western medicine is seen as powerful and effective, if it is known that a medical team is coming, some may delay getting necessary healthcare. The fact that many healthcare missions provide free care adds to the delay in seeking medical attention until the mission team arrives (Montgomery, 2000). Sometimes mission teams don't keep in mind the work of local healthcare providers. The care provided by the mission team may conflict with the ongoing plan of care provided by the local provider. How might we feel if someone from another country or state came to our community, held a healthcare outreach that treated our patients for free, without including us in the plans?
We work hard to earn our degrees and licenses to practice nursing in the United States. Nurses in other countries have done the same. We need to respect their efforts and submit our credentials in order to become licensed in the countries where we serve. Getting a nursing license, temporary or official, may require "jumping through some hoops," but it communicates respect and appreciation for the nursing authorities in the host country.
The challenges of short-term healthcare missions should not lead to the conclusion that short-term missions should be abandoned. Healthcare opens doors that cannot be opened by traditional missions. Countries that limit access to missionaries often welcome healthcare professionals to provide care and teach their disciplines. Healthcare outreaches can be used to augment mission efforts and provide needed physical care not available through local churches. Repeatedly returning to an area can build trusting relationships with local healthcare providers, provide training, and assist them in giving quality care. Short-term healthcare missions can have a great impact when the focus is on what is left behind and who will care for the people when we leave.
Trend 5: Moving away from being sent by mission organizations to participating in church-to-church partnerships or setting up nonprofit organizations. The ease of travel and communication, ability to go abroad for short periods, exposure to the immense healthcare needs among the world's poor, and the desire to be personally involved in mission endeavors have led many healthcare professionals to strike out on their own. Applying to a sending mission organization that may require academic preparation in Bible, language, and culture, essays on topics such as doctrine and mission philosophy, and character references, leads some candidates to see mission sending organizations as cumbersome or perhaps unnecessary. Adding time for additional academic requirements in addition to raising financial support seems burdensome to young professionals eager to get to work. If a nurse has a contact in another country and wants to go for a short-term mission, it is not unusual to arrange privately for a trip.
Although mission sending organizations may seem stodgy, complicated, or inefficient, they play important roles. Careful screening helps to ensure missionaries have the needed tools to live and work cross-culturally. Sending organizations have experience in budgeting, fund development, and accounting of donations. Usually some provision is made for retirement benefits and health and life insurance. They have assigned staff who understand and can anticipate the physical, emotional, educational, and spiritual needs of missionaries and their families. The leadership has carefully thought through responses to untoward health, political, or disaster situations. Sending organizations prepare for and assist missionaries in dealing with situations such as a military coup d'état, a severe accident/injury, or even kidnapping. I am appreciative of a mission sending organization and its support after living through two coups, losing a valued colleague in a vehicle accident, and being present during the initial phase of the HIV/AIDS epidemic when much was unknown and people were dying daily. Rarely are those who go abroad on their own recognizance equipped to fill the roles that sending mission organizations perform.
Churches are seeing the benefits of developing relationships with churches in other countries. Thanks to technology, we can more readily engage in relationships with Christians worldwide. Church members who go on missions trips to sister churches are able to become involved in the work themselves, see how their money is used, and feel a part of the mission endeavor. Involvement cross-culturally leads to spiritual growth and commitment by those who participate in church organized missions. Church-to-church relationships can be extremely beneficial if done well. Ideally the exchange will be in two directions—church members from abroad will be invited to visit the United States as well as U.S. churches sending members to sister churches abroad. It helps to have a bridge person, someone who is conversant with both cultures to explain values and behaviors to members of the other congregation. True partnerships will spell out a common goal and each party's responsibility in reaching that goal. Often the term "partnership" is used in place of "sponsorship."
One of the dangers in church-to-church arrangements is building a dependency that is harmful to the church at large. Recent books by Steve Corbett and Brian Fikkert, When Helping Hurts (2009), and Glen Schwartz in When Charity Destroys Dignity (2007) examine some of the challenges of these relationships.
Sometimes a decision is made to begin a nonprofit organization to assist in meeting identified health needs such as building a clinic, supplying equipment and pharmaceuticals, or teaching basic healthcare. This has led to a plethora of nonprofit organizations. All are passionate about their work and desire to meet the healthcare needs of the poor. But good intentions do not always lead to good practice. Legal and accounting details may get overlooked through naiveté; board members can be family and friends who share in the vision and mission but may not have experience in nonprofit management. Taking time to study what is involved in beginning and running a nonprofit organization can preclude mistakes that will require remediation later.
THE FUTURE OF HEALTHCARE MISSIONS
We are living in exciting times. Although many bemoan electronic medical records, computer viruses, and the tension of being available 24/7, there are great opportunities as well. Just as the Romans built the roads that enabled the Gospel to reach the known world, so the Internet and technology are allowing the Gospel message to circulate the globe.
Online nursing education has tremendous potential for educating nurses in remote locations. Many mission hospitals cannot spare sending nursing staff for continuing or further education. But with the Internet, satellite communication, and shared technology, it might be possible to provide nursing education to those nurses. Just as we are looking to nursing to improve healthcare in the United States, one way to improve healthcare around the world would be to educate nurses in their own countries.
As a global society, establishing partnerships between educational, religious, and governmental institution is more common. We need to guard against U.S. pride in thinking we have all the answers, vying for position and recognition or becoming jealous of others' success. We need to collaborate, share ideas, help each other improve, appreciate the dignity of each person created in the image of God, and respect each other's talents and gifts. We represent Jesus Christ and his Church. John 13:35 states, "By this all men will know that you are my disciples, if you love one another." Global healthcare needs are too great to not join forces to bring health and healing to the nations.
Alma Ata Declaration. (1978, September 12). Declaration of Alma-Ata. Proceedings of the International Conference on Primary Health Care, Alma-Ata, Union of Soviet Socialists Republic (USSR). Retrieved from http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf
- Luke Society—http://www.lukesociety.org/
- LifeWind International— http://www.lifewind.org
- Global Community Health Education Network— http://www.chenetwork.org
- Best Practices in Global Health Missions— http://csthmbestpractices.org